Michelle is at a free clinic and is uninsured. Who will pay for the testing that you recommend like CBC, IgE, and spirometry?
CBC and spirometry are the only tests prescribed by me for Michelle me as mandatory. The first test is not prohibitively expensive, and the patient should be able to afford it if she can pay for the medications. Spirometry costs considerably more, but as it is scheduled to happen 2 or 3 months from now, Michelle should be able to save enough money given sufficient warning. As such, I believe she can pay for the testing if necessary. However, a situation where the patient cannot afford the procedure is possible, and alternatives should be explored. It is likely that an organization that helps less affluent people without insurance is nearby and can assist Michelle.
What do the guidelines recommend for further testing when a diagnosis of asthma has been made based on patient symptoms and PFTs?
The result of a PFT may not be conclusive, and so it is necessary to consider other possible diagnoses. The National Heart, Lung, and Blood Institute (2007) recommends additional studies, bronchoprovocation, a chest x-ray, allergy testing, and biomarkers of inflammation, to identify or rule out other potential conditions. The guideline by Global initiatives for asthma (2017) shows similar suggestions, but limits the options to bronchial provocation, allergy, and exhaled nitric oxide tests, suggesting that spirometry with a reversibility test that supports the asthma diagnosis is sufficient to begin treatment.
Williams, Schmidt, Redd, and Storms (2003) indicate that the patient should be referred to a specialist if the diagnosis is uncertain or if the condition may be influenced by occupational exposures, which is the case in the present scenario. Ultimately, however, the scope of the question restricts it to suggesting the array of tests provided above, with preference given to the newer guideline.
Given Michelle’s history of allergic rhinitis, what do the GINA guidelines (Global Initiative for Asthma) support as a therapeutic option(s)?
Allergic rhinitis suggests a need to use slightly different medicinal options than usual. The Global initiatives for asthma (2017) guideline note that leukotriene receptor antagonists may be appropriate for Michelle, though they are less effective than ICS in the general scenario. Furthermore, Global initiatives for asthma (2017) propose the use of sublingual immunotherapy if the patient is sensitive to house dust mites. However, Michelle feels fine at home, which eliminates the possibility and makes the treatment unnecessary.
Nevertheless, the guideline suggests the use of specific measures to address the patient’s allergic rhinitis. Global initiatives for asthma (2017) point out that the use of intranasal corticosteroids in response to the condition reduces the incidences of asthma-related hospitalizations and emergency department visits, unlike nasal mometasone, which has no effect on the same statistics. As such, the guideline suggests that Michelle should undergo the first treatment, although the matter of her financial situation remains in question.
What guidance can you provide Michelle so that she will know definitely that her symptoms are not controlled?
Asthma symptoms can be complicated, and so guidelines do not include the full list and suggest that the practitioner should refer the patient to a separate plan or flowchart. The National Heart, Lung, and Blood Institute (2007) provides a chart that mentions the patient missing work, waking up at night, believing his or her asthma is well controlled, and frequently using an inhaler, but cautions that the questionnaire does not assess the risk domain. It does not provide a tool to measure the characteristic, although there are suggestions as to the indicators.
Nevertheless, keeping track of one’s symptoms is an essential and helpful activity. Global initiatives for asthma (2017) offer a set of suggestions for short-term and long-term monitoring through the use of peak-flow monitoring using a chart that can be obtained from numerous online sources. The goals include observing exacerbation recovery and changes in treatment, which are appropriate for Michelle, and identifying domestic and occupational triggers, which are not. Ultimately, the approach warrants consideration and potential adoption for self-monitoring.
References
Global initiatives for asthma. (2017). Global strategy for asthma treatment and prevention. Web.
National Heart, Lung, and Blood Institute. (2007). Expert panel report 3: Guidelines for the diagnosis and management of asthma. Web.
Williams, S. G., Schmidt, D. K., Redd, S. C., & Storms, W. (2003). Key clinical activities for quality asthma care: Recommendations of the National Asthma Education and Prevention Program. MMWR Recommendations and Reports, 52(RR-6), 1-8.