Develop A Comprehensive Respiratory Care Plan For A 65-Year- ✓ Solved

Develop a comprehensive respiratory care plan for a 65-year-

Develop a comprehensive respiratory care plan for a 65-year-old female with asthma and congestive heart failure (CHF) presented with severe wheezing, shortness of breath, and coughing. Based on the provided case data, include assessment, diagnoses, therapeutic management, patient education, evaluation, and follow-up. Address medication considerations and potential interactions (e.g., Theophylline and Phenytoin), non-pharmacologic therapies, and monitoring parameters. Present the final paper as a 1000-word analysis with in-text citations and a references list.

Answer with a clean, well-structured, evidence-based paper that analyzes the clinical data, formulates a detailed plan for treatment and monitoring, and includes patient education steps and a follow-up schedule.

Paper For Above Instructions

Introduction

The patient is a 65-year-old female with a history of episodic asthma since her 20s and chronic heart failure (CHF). She presents with severe wheezing, dyspnea, and coughing daily, with limited ability to speak without breath pauses. Current medications include Theophylline SR 300 mg BID, albuterol inhaler PRN, Phenytoin SR 300 mg QHS, hydrochlorothiazide 50 mg BID, and enalapril 5 mg BID. Her recent vital signs are notable for hypertension (BP 171/94), tachycardia (HR 122), tachypnea (RR 31), and signs of anxiety. Baseline spirometry shows peak flow 75/min, FEV1 1.8 L, FVC 3.0 L, and FEV1/FVC 60%, consistent with mild persistent asthma with acute exacerbation and coexisting CHF. Theophylline level is low (6–6.2 µg/mL), and Phenytoin is variably reported. This clinical scenario requires a integrated approach, addressing asthma control, heart failure management, and potential drug interactions, particularly theophylline–phenytoin interplay and the subtherapeutic theophylline exposure in the context of CHF and polypharmacy (CDC, 2019; NHLBI, 2007).

Assessment and Diagnostic Synthesis

The patient has three intertwining conditions: asthma with acute exacerbation, CHF, and a history of COPD-like symptoms given wheezing and reduced respiratory reserve. Objective data indicate significant airway hyperresponsiveness (expiratory wheezes, elevated RR, reduced peak flow) and radiographic findings compatible with pleural effusions or cardiomegaly risk in CHF. The combination of elevated BP (171/94), tachycardia, and ankle edema supports volume overload and cardiac involvement. The respiratory status is further complicated by a subtherapeutic theophylline level, which may reflect either poor adherence, metabolic induction, or drug interactions (e.g., with phenytoin). Because theophylline has a narrow therapeutic window and is affected by cytochrome P450 induction (phenytoin is a known inducer), careful consideration is needed before increasing theophylline dose (Fischbach & Dunning, 2017; CDC, 2019). The differential includes uncontrolled asthma with acute exacerbation, CHF-related dyspnea, and possible COPD overlap. The patient’s medication list, including ACE inhibitors and diuretics, requires monitoring for potential interactions and renal/hepatic function implications (NHLBI, 2007; Yancy et al., 2017).

Diagnoses

  • Primary: J45.31 Mild persistent asthma with acute exacerbation
  • Secondary: I50.43 Acute on chronic combined systolic and diastolic CHF
  • Tertiary: J44.9 COPD, unspecified
  • Supporting: Hypertension; Ankle edema; Anxious mood; Subtherapeutic theophylline with potential drug interactions (theophylline–phenytoin)

These diagnoses reflect the need for a dual-focused management plan that improves asthma control while optimizing heart failure therapy and monitoring for adverse interactions, particularly those affecting respiratory and hemodynamic status (GINA, 2023; GOLD, 2023; NHLBI, 2007; CDC, 2019).

Therapeutic Management Plan

Asthma control: Initiate/step up anti-inflammatory controller therapy in alignment with guideline-based asthma management. Given a history of persistent symptoms and current theophylline use, prioritize inhaled corticosteroids (ICS) combined with a long-acting β2-agonist (LABA) if needed for control, and reassess the role of theophylline due to its narrow therapeutic index and interactions with phenytoin. A typical step-up approach could include initiating an ICS/LABA inhaler (e.g., budesonide/formoterol) and optimizing inhaler technique and adherence. Continue albuterol as rescue bronchodilator with a clear action plan. Monitor FEV1 and peak expiratory flow rate (PEFR) to gauge response (GINA, 2023; NHLBI, 2007). In the interim, reassess theophylline necessity and consider tapering if control is achieved and alternative controllers are effective (Merck Manual, 2021).

Cardiovascular optimization: CHF management should continue with enalapril and HCTZ, with careful monitoring for hypotension, neprho-vascular responses, and electrolyte balance, particularly potassium and creatinine given diuretic use and possible interactions with other medications. Sodium-restricted diet and fluid management should be reinforced; consider a CHF-focused evaluation with echocardiography as needed to assess ejection fraction and guide therapy (Yancy et al., 2017; NHLBI, 2007). Vaccination advice (influenza, pneumococcal) and lifestyle measures (smoking avoidance, physical activity as tolerated) should be incorporated into the plan (CDC, 2019).

Medication reconciliation and interaction management: Phenytoin induces hepatic enzymes, potentially accelerating theophylline clearance and contributing to subtherapeutic levels, while theophylline can interact with other cardiac and CNS agents. A systematic review and consideration of alternative non-pharmacologic therapies may be warranted to mitigate adverse interactions and optimize asthma control. Consider converting or reducing theophylline exposure by substituting ICS/LABA therapy and ensuring proper monitoring for adverse effects or relapse (Fischbach & Dunning, 2017; Merck Manual, 2021).

Non-pharmacologic strategies and education: Educate on trigger avoidance (pollutants, allergens), proper inhaler technique, and adherence strategies. Provide a written asthma action plan and a CHF action plan, including red flags (worsening dyspnea, chest pain, edema, weight gain) and when to seek urgent care (CDC, 2019; NHLBI, 2007). Lifestyle modifications targeting weight reduction, exercise as tolerated, and dietary sodium restriction are essential components of holistic management.

Education and Self-Management

Empower the patient with knowledge about asthma triggers, peak flow monitoring, and when to escalate therapy. Teach inhaler techniques for all devices used (metered-dose inhalers with spacer if applicable). Provide a clear, written action plan detailing daily management, stepwise therapy changes, and urgent follow-up instructions. Emphasize the importance of medication adherence, recognizing signs of theophylline toxicity (nausea, tremor, tachycardia, insomnia), and the potential for drug interactions with antiepileptics and cardiac medications (CDC, 2019; NHLBI, 2007).

Monitoring, Follow-Up, and Evaluation

Schedule follow-up within 2–4 weeks after initiation or modification of therapy to assess asthma control, symptom frequency, spirometry values, and rescue inhaler use, as well as CHF status (BP, weight, edema). Objective measures (FEV1, FVC, peak flow) should guide therapy adjustments; monitor theophylline level if theophylline therapy remains in use, with a goal range and adjustments for interactions with phenytoin and hepatic function (NHLBI, 2007; Corren, 2020). Regularly reassess risk factors, adherence, and environmental triggers; reinforce vaccination status and pulmonary rehabilitation as appropriate for COPD overlap or chronic respiratory disease (GOLD, 2023; Spruit et al., 2013).

Expected Outcomes

Improved asthma control with fewer exacerbations, stable or improved FEV1 (target >80% predicted if possible), reduced rescue inhaler use, and stabilization of CHF symptoms with controlled edema and blood pressure. A stable theophylline level within a therapeutic range without signs of toxicity or significant drug interactions would be desired if theophylline remains part of therapy, otherwise a transition to ICS/LABA-based asthma control with IPA adherence would be pursued (GINA, 2023; CDC, 2019; Yancy et al., 2017).

Conclusion

This patient presents a complex intersection of asthma and CHF with polypharmacy and potential theophylline interactions. A safety-first approach prioritizes stepping up to guideline-based controller therapy for asthma, optimizing CHF management, and minimizing theophylline-related risks by evaluating the necessity of the drug in the face of effective alternatives. A comprehensive plan including patient education, close monitoring, and timely follow-up can improve respiratory control, cardiovascular stability, and overall quality of life.

References

  • Centers for Disease Control and Prevention (CDC). (2019). Asthma. Retrieved from https://www.cdc.gov/asthma/index.html
  • Centers for Disease Control and Prevention (CDC). (2019). COPD. Retrieved from https://www.cdc.gov/copd/index.html
  • Global Initiative for Asthma (GINA). (2024). Global Strategy for Asthma Management and Prevention. Retrieved from https://ginasthma.org/
  • National Heart, Lung, and Blood Institute (NHLBI). (2007). Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma. NIH Publication No. 08-4051.
  • Yancy, C. W., Jessup, M., Bozkurt, B., et al. (2017). 2017 ACC/AHA/HFSA Focused Update: Management of Heart Failure. Circulation, 136(6), e137–e161.
  • Global Initiative for COPD (GOLD). (2023). Global Strategy for Diagnosis, Management and Prevention of COPD. Retrieved from https://goldcopd.org/
  • Spruit, M. A., et al. (2013). An official ATS/ERS statement: Pulmonary rehabilitation in COPD. American Journal of Respiratory and Critical Care Medicine, 188(8), e64–e92.
  • Fischbach, F. T., & Dunning, M. P. (2017). A Manual of Laboratory and Diagnostic Tests (10th ed.). Philadelphia, PA: F.A. Davis.
  • Corren, J. (2020). Evaluation and treatment of asthma: An overview. Current Opinion in Allergy and Clinical Immunology.
  • Merck Manual Professional Version. (2021). Theophylline: Drug interactions and clinical pharmacology. Retrieved from https://www.merckmanuals.com/professional/

Related Assignments