I thought you did an excellent job identifying a cause of the patient’s asthma as well as choosing a severity and classification for her diagnosis. Both of these are needed in a patient with a new or chronic asthma diagnosis. I’m trying to get a sense of what National Guideline were used in your treatment plan and diagnosis. I see an article referencing the NAEPP, but do not see the actual guidelines in your references. Did you come across any EBP sources within the past 5 years since the source you cite is from 2008? If you did not, then it would be important to make sure you indicate awareness that the sources are > 5 years old.

I’d like for you to research the STEP approach to managing asthma….unless your preference would be GINA or something similar. This is one of the most widely used tools to manage asthma and I think it will help you fine tune your medication plan. In mild persistent asthma, according to the STEP approach, is a LABA indicated? and what do those guidelines say about the use of an ICS? Remember, in this course, all of your rationale should be coming from national guidelines, rather than textbooks. So while CURRENT is a good secondary source or place to look for some guidance, this course challenges you to find pathways and guidelines to support your plans.

Tell me more about the referrals for this first line plan. The allergist is a potential referral especially given her history but according to the source you cite, I’m struggling to see how this patient qualified for a referral to a pulmonologist for mild persistent asthma. You indicated a referral may be “recommended anytime there is a life-threatening exacerbation, the patient is not meeting their goals after being on therapy for 3-6 months, the patient’s signs and symptoms are atypical or the differentials are unclear, comorbidities are complicating the condition.” How do the case details for this patient support this?

You have some good general ideas for this plan, but there needs to be rationale and research to support your ideas. For example, I think your plan to repeat spirometry is reasonable. What will you specifically be looking for to evaluate efficacy of your treatment plan? and what is your interval for re-testing? What specific symptoms should the patient go to the ER for? What education will be important for her medications and management of her symptoms?

I’d like to see you find some support for how to manage not only mild persistent asthma but also occupational asthma so you can be as specific to this patient’s diagnosis that you have made as possible. This will be very helpful in clarifying and including things that are not only relevant but also pertinent to not only management this patient’s new diagnosis, but to provide primary care as well.

What other medications may be helpful to consider here given the patient’s occupational exposure to an irritant as well as her PMHx of allergies and childhood eczema?

One of the things that surprised me in your discussion of antibiotic use was the following: “While some studies are increasingly advocating for antibiotics as an important part of the medications for addressing asthma, it is still very isolated.” Can you tell me more about this? In this patient, are there any clinical indications for her to be prescribed an antibiotic? I’m hoping you can clarify the sentiment that antibiotics are a last resort in this patient’s situation.

Lots to consider here. I’m looking forward to your response!

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