The purpose of this article is to evaluate the challenges posed during the care and management of patients and how it can influence our clinical decision-making. It will seek to explore the evidence behind the treatment plan and explain the reasoning. The case will focus on a twenty eight year old male patient presenting with an exacerbation of asthma following a productive cough. This case was selected as it demonstrates clinical examination and formation of differential diagnoses in addition to highlighting legal and ethical barriers, and will discuss the clinical examination performed and the psychosocial factors affecting the treatment and management plan. It will explore the treatment options with consideration of legal and ethical principles. The case will be anonymous with no identifiable information available (Data Protection Act 1998).
History-taking and examination
A medical model approach was used to examine the patient, which consisted of thorough history taking (Douglas, Nichol and Robertson 2013). This indicated a one-week history of productive cough with copious thick green sputum, coinciding with an increasing inhaler use of twelve to fourteen puffs of ‘Ventolin’ per day; little effect. The patient reported a reduced exercise tolerance and being short of breath on moderate exertion. No haemoptysis was reported and there was no history of chest pain, recent travel, calf swelling or familial history of hyper-coagulopathy disorders. The patient works as an electrician and smokes ten filtered cigarettes a day with a weekly alcohol consumption of ten to twelve units. In addition the patient is a competitive sportsman with a competition in 3 weeks.
The assessment of this patient focused primarily on the respiratory system as the history indicated an exacerbation of asthma with a potentially infectious cause. Guided examination is considered safe and effective when coupled with a thorough patient interview (history taking), however, consideration was given to a holistic approach and multi-system involvement. Auscultation has been shown to be the most effective method of examining a patient's respiratory pathology in the first instance (Gregory and Ward 2010). However, sources cite that it should not be used in isolation (Gregory and Ward, 2010; Bickley, 2013; Douglas et al, 2013). Techniques used during auscultation included testing for broncophony, egophony and whispered pectoriloquy as a determinate for consolidated tissue indicative of pneumonia. The use of whispered pectorilogy however is controversial with Newnham et al. 2011 branding it unreliable and lacking favour with senior clinical assessors whilst Douglas et al. state it is useful to form and exclude differential diagnoses.
The patient had negative findings for broncophony, egophony and whispered pectoriloquy, presented as normoresonant and no evidence of tactile vocal fremitus indicating a reduced likelihood of pneumonia and pleural effusion (CI 0.12-0.37) (Wong et al. 2009). Further assessment indicated a global faint expiratory wheeze, unilateral basal crackles, mild pyrexia, normal sinus rhythm shown on their ECG (no S1Q3T3), respiratory rate of 18 per minute, saturations of 95% on air and a Peak Expiratory Flow Rate (PEFR) of 70% of previous recordings. The totality of this amounted to a working diagnosis of a Lower Respiratory Tract Infection (LRTI) exacerbating the patients underlying chronic asthma (Douglas, Nichol and Robertson 2013, McCance et al. 2010 and Porth and Matfin 2009). Unilateral crackles presenting with lack of consolidation or effusion coupled with a normal ECG and not recent travel or calf pain lead to the decision that Community Aquired Pneumonia (CAP) or Pulmonary Embolism (PE) were unlikely diagnoses (Wong et al. 2009; Gregory and Ward 2010 and Douglas, Nichol and Robertson 2013). The likely diagnosis for this patient was an uncomplicated lower respiratory tract infection (LRTI).
Smoking
Psychosocial factors influence a holistic approach to the patient and should be considered as part of the assessment. The patient presented a unique challenge due to being a smoker and an athlete. Smoking presents a problem for patients presenting with respiratory tract infections as it not only increases the likelihood of contracting an infection but will also increase the recovery period needed (Porth and Matfin 2009; McCance et al, 2010). However, this should not negate from treatment. Eidence suggests that smoking decreases lung function, as presented in a study by Xu et al, whereby 8 191 participants had the PEFRV1 measured; three follow-ups conducted over a 6-year period. This study showed that the average 52.9ml per year decline in lung function when continued smoking but the best benefits can be gained by smoking cessation at a younger age (Xu et al, 1992). Although the data from this study is now over 20 years old, it remains relevant as this was a large, high powered and multi-site study which has not been replicated on the same scale since, due to its clarity and rigorous methodology. A cultural issue that arose during examination was that the patient works on a building site whereby there is a strong smoking culture, which in the past has proved an issue when trying to quit.
Asthma and doping
The patient was also very concerned about any treatment they might receive as they are a competitive sportsman and whilst wanting to be fit enough to compete in 3 weeks, the patient did not wish to be treated with any substances that may count as doping under international competitive rules (World Anti-Doping Agency 2016). An important aspect of psychosocial care is considering the patient's occupation and how the current illness may affect their ability to perform their role. The patient was self-employed as an electrician and was becoming short of breath over the last few days whilst performing his normal work and was concerned that if he deteriorated further he would not be able to work and would lose income. It is known that a self-employed worker is likely to earn 50% less than expected if diagnosed with a chronic disease which is known to then impact on other aspects of their life (Meenan et al, 2005).
Guidelines on asthma
Guidelines for the treatment and management of acute asthma are set out by a number of bodies including the National Institute for Health and Care Excellence (NICE), British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN) and the Royal Pharmaceutical Society (RPS); the majority of recommendation comes from the BTS and SIGN. The patient was already prescribed a short acting beta-2 agonist (Salbutamol as Ventolin inhaler) and so fulfills the step one management plan (RPS 2015, SIGN 2011, BTS 2011, and NICE 2013).
Asthma, steroids and doping
The guidelines recommend addition of a short course of corticosteroids during the acute phase and review after with a view to step down (RPS 2015; SIGN 2011; BTS 2011; NICE 2013). However, the Royal Pharmaceutical Society recommends the use of oral prednisolone 5 mg dose for five days in preference to inhaled Beclometasone Dipropionate as it has been shown to increase the risk of LRTIs, and a reduction in bone mineral density (RPS 2015), although this is normally considered a risk in long-term use. The use of a short course of oral prednisolone is that it allows for an easy step-down on treatment (RPS 2015, BTS 2011 and SIGN 2011) and therefore considered as the treatment of choice for this patient. Prednisolone is also not currently included on the list of banned substances for athletes (WADA 2016) and therefore was suitable for the patient.
Consideration was given for a long acting beta-2 agonist inhaler namely Salmeterol, recommended in the first line (RPS 2015, SIGN 2011 and BTS 2011), due to increased use of a Salbutamol inhaler however this was negated secondary to patient concern about their upcoming competition. Salmeterol is currently included on the banned substances list by the World Anti-Doping Agency (WADA 2016). This is potentially due to its pharmacology preventing exercise-induced asthma (RPS 2015). The limit for Salbutamol as set by the WADA is 1600 micrograms in a twenty-four hour period (WADA 2016). Therefore the 1200-1400mcg cumulative daily doses the patient was currently self-administering came under this limit.
However, it is known that the excessive administration of the inhaled beta-2-agonist salbutamol can result in side effects ranging from fine tremors and palpitations to hypokalaemia and lactic acidosis in high doses (RPS 2015; Rang and Dale, 2011; and Galbraith et al, 2007). A risk-benefit analysis was performed and deemed that although the patient was medicating currently at double the daily dose (RPS 2015), it had been for a short period of time and was envisaged to reduce with complimentary treatment of oral corticosteroids.
Antibiotics, allergies and asthma
With the patient presenting as an LRTI, consideration must be given to the dispensing of antibiotics for treatment; local policies can vary greatly. Factors influencing the choice of antibiotic dispensed include allergens, renal and hepatic function, co-pharmacy and consideration of the likely causative organism (RPS 2015), and considering the affected system or systems. When treating an uncomplicated respiratory tract infection, it is likely that the microorganism is a pneumococci; however, there remains the possibility of a staphylococci derivative (RPS 2015; BTS 2011; NICE 2013; McCance et al, 2010; Porth and Matfin, 2009). First-line treatment is recommended as Amoxicillin 250 mg–500 mg every 8 hours (RPS 2015 and NICE 2015). The patient in question had a known severe Penicillin allergy; the Royal Pharmaceutical Society recommends Doxycycline or Clarithromycin as alternatives.
Joks and Durkin authored a pharmacological paper in 2011 whereby they hypothesise the use of tetracycline actually works to reduce the Immunoglobulin-E response and therefore medicate the allergic asthma response (Joks and Durkin, 2011; McCance et al, 2010) thus aiding the asthmatic patient when prescribed long-term. However, this paper is largely prospective, pharmacological and has not yet been developed into a full-randomised control trial. Consequently, it cannot be used as a definitive paper.
Local policy and national guidelines recommended the use of Macrolides as first-line treatment for LRTI in penicillin allergic patients due to is similar spectrum, therefore the patient was started on a 7 day course of Clarithromycin 250mg twice daily as recommended (RPS 2015 and NICE 2015). This was dispensed alongside general antibiotic advice as recommended by NICE including the reiteration that the patient must finish the full course of antibiotics even if they start to feel better (NICE 2015) further addressing the psychosocial aspects of care.
Long term management
To aid the treatment of the patient's condition and improve their long-term health, it was recommended that the patient cease smoking (NICE, 2008; BTS, 2011). Although, currently accurate and relevant smoking cessation advice is not clearly defined within the scope of practice as set out by the Health and Care Professions Council (HCPC) and the College of Paramedics (CoP), emphasis is on clinicians to promote the health of the nation (HCPC 2014 and CoP 2015). It was identified that paramedics are commonly not proficient in providing specific smoking cessation advice, therefore the patient was referred to specialist services including the ‘NHS smokefree’ service and their own General Practitioner who provided a multi-faceted approach (Ewels and Simmnett 2003; NICE, 2008; NHS N.D.). Identifying areas of lacking ability and referral to other services fulfils the standards set out by the HCPC and ensures a safe legal practice (HCPC 2014).
Written management plans and regular reviews can reduce the impact of chronic asthma (Asthma UK, 2016; SIGN, 2011; NICE, 2013), reviews by GPs and specialist Asthma Nurses allow the patient to discuss triggers and their self management, decreasing the likelihood of presenting as an acute episode. Loenen et al (2015) challenge this and state that general reviews in primary care do not reduce the overall level of avoidable hospitalisation. Loenen et al correlated a reduction in hospital admissions hinged on other factors, for example a named GP who is aware of the individual's social and cultural factors.
Health promotion
Males are less likely to seek medical help for illnesses (Hunt et al, 2003). Government initiatives are aiming to tackle this, the most prominent being the ‘make every contact count’ campaign (Varley and Murfin N.D. and Soni and Bailey N.D.). The purpose of the initiative is to ensure that every patient contact is used not only for the presenting complaint, but to promote health encompassing the psychosocial aspects of care. Utilising the episode whereby this patient presented to suggest a review by their GP and Asthma Nurse is in accordance with this guidance and the guidelines from SIGN and NICE; this seeks to promote the individuals future health.
Health promotion is also an integral aspect of any patient contact episode especially in male patients who are less likely to present (Ewels and Simmnett, 2003); often time can be used for vaccination advice. Vaccination against common conditions including the flu is highly recommended in adults with respiratory conditions including asthma to prevent the development of pneumonia (Asthma UK 2015 and NHS 2015). It was therefore recommended to this patient to seek the flu vaccination each year either through their own GP or local pharmacy (not whilst suffering from an active infection) (NHS 2015).
PGDs, prescribing and paramedics
The treatment and management of this patient highlights a number of legal and ethical issues with the principal dispute surrounding the use of non-medical prescribing and dispensing of medications under Patient Group Directions (PGDs). The use of non-medical prescribing is widely incorporated into the National Health Service framework with nurse prescribers providing an essential service in areas such as primary care and emergency medicine (Commission on Human Medicines, 2015). Following a recent ruling by government (Commission on Human Medicines 2015), Paramedics are currently unable to prescribe due to a lack of clarity on advanced roles and a wide variety of presenting conditions; this is being contested (College of Paramedics, 2016).
The College of Paramedics takes the stance that paramedics should have access to full independent prescribing rights, and is working with NHS England to collate a new proposal (College of Paramedics, 2016). Therefore, it is likely that as the role progresses, independent prescribing for advanced practitioner roles may become a reality. Currently, medicines are dispensed either by the counter signature of a prescriber or dispensed under PGD's which have been shown to be safe and effective for emergency care (Commission on Human Medicines, 2015). In the future advanced paramedics could have prescribing rights, albeit with limited formulary, which would greatly benefit this scenario whereby the patient could be treated at point-of-contact.
Commission on Human Medicines raised concerns in 2015 regarding microbial resistance and the administration of antibiotics by non-medical prescribers (Commission on Human Medicines 2015), which apply to the case in question. Antibiotic prescription is closely monitored to avoid antibiotic resistance (Commission on Human Medicines 2015 and NICE 2015) and schemes are in place to reduce unnecessary administration and poor compliance; namely the antibiotic guardians scheme (Public Health England 2016). It is important to assess the patient's likely compliance when considering antibiotic dispensing; the patient in question was very keen to be healthy to compete soon and therefore is likely to be compliant with medications. Assessing the patient in a holistic manner and encompassing the psychosocial aspects of care can lead to greater affinity with healthcare professionals and the management plans (Ewels and Simmnett, 2003).
Ethics
An ethical concern arises from the case in question as to whether it is appropriate to consider altering management plans for patient's activities as opposed to cultural, religious or legal associations. Ethicality of treatment, as proposed by Pera and Tonder (2005), centres on a patient focused approach and must encompass the patient as a holistic entity. Ethical principles in healthcare stem from the common themes of ‘Primum non nocere’ or nonmaleficence, meaning the healthcare provider should, above al, l do no harm. This is considered in parallel with the ideology of beneficence meaning to ‘always do good’ (Pera and Tonder 2005; Gillon 1985). It may be considered that, providing treatment is not withheld, considering alternatives that are safe, effective and within guidelines it may be appropriate to alter management plans. The patient may be more likely to agree with the treatment, and comply, if they feel their psychosocial needs have been attended to by the healthcare professional (Ewels and Simmnett 2003).
Summary
To summarize the patient's management plan, after discussion with a prescriber, the patient was prescribed a 7-day course 250mg Clarithromycin twice daily, a 5-day course of 5mg Prednisolone once daily and a repeat of their own Ventolin inhaler. The patient was also given basic smoking cessation advice and signposted to specialist services. This was recommended concurrently with a review by the patients own GP and Asthma Nurse that should include discussions regarding the flu vaccine, increasing symptoms and this acute episode. The patient was provided with detailed written worsening care advice alongside verbal advice utilizing a closed loop communication (Härgetsam et al 2013) to ensure the patient understood where and how to access help.
Conclusion
This discussion presents a clinical assessment and has identified how the diagnosis of a lower respiratory tract infection and exacerbation of asthma was arrived at. It has critically examined the psychosocial aspects of the patient scare, addressed these directly, and shown alternative management plans whilst considering ethicality. The patient has been considered holistically and signposted to appropriate services to assist in managing the cultural barriers to quitting smoking. The treatment and management plans have been discussed critically with supporting literature assessed for acumen and relevance with consideration given to the correct antibiotic choice, clarithromycin over doxycycline, and use of corticosteroids. Management plans have been collated with consideration for the most appropriate guidelines for the condition, namely the SIGN, NICE and BTS guidelines. The case presented a number of professional and legal considerations with the foremost being concerns regarding non-medical prescribing and the future for paramedic prescribing and critically examined these. The ethicality of altering management plans may be suitable in certain situations.