Rosie Timmins is a 60 year old female, asthmatic since she was 15 years of

age. Until age 40 years, she was almost totally asymptotic except for the
spring time when she would become very congested and wheezy with the
fresh pollens in the air. She was allergic to cats. Her ABGs remain normal. At
age 40 she became progressively more symptomatic, having bronchospasms
with any exertion, worsened during cold weather, coughing, audible
wheezing and shortness of breath. Her pulmonary function tests at this time
showed forced expiratory volume in 1 second (FEV1.0) as significantly
reduced. Both her FEV1 and forced vital capacity (FVC) improved following
administration of an inhaled bronchodilator. At this time she started to
routinely use the following inhalers: ipratropium bromide 2 inhalations, BID,
up to QID prn; salmeterol 1 inhalation BID; budesonide 1 inhalation BID;
montelukast (Singulair) 10 mg daily, HS. As long as she continued to take the
mediations as recommended her symptoms were well under control.
Occasionally when she developed severe bronchospasms she increased her
dosage of inhalers. This increase in dosage was consistently followed by
episodes of palpitations, nervousness and restlessness. She also struggles
with frequent candidal throat infections (opportunistic infections), which she
states is extremely annoying. Every fall she makes sure to get the
recommended flu shot.
A year ago, at age 59 she was diagnosed as having emphysema. Her ABGs
on room air at the time of diagnosis were pH 7.35, pO2 82, pCO2 48, bicarb
29. Now when she is admitted to hospital she is on supplemental oxygen at 2
L/min N/P. Her respiratory rate is 18/min, prolonged expiratory phase,
wheezes present on expiration, using accessory muscles and pursed lip
breathing with and after any exertion. She is beginning to develop an
obvious barrel chest. She has lost some weight and is beginning to appear a
bit emaciated. Pulmonary function tests show increased expiratory reserve
volumes, decreased inspiratory capacity and increased total lung capacity.
On admission to hospital her heart rate is irregular at a rate of 100 beats/min
with ECG showing atrial fibrillation. She was started on propranolol to control
her heart rate and she promptly went into serious life threatening
bronchospasm. Fortunately she did not require artificial ventilation and her
medication was changed to diltiazem without further complications.
1 Why does Rosie become congested and wheezy when exposed to pollens,
cats and later also with exertion and exposure to cold air?
2 Given the mechanisms that cause edema, what is causing edema with
asthma and why/how?
3 People often think that asthma is a problem with getting air in, how do
Rosies pulmonary function tests show that it is an obstructive disease
and therefore primarily a problem with exhalation?
4 What is the purpose of each of the inhalers prescribed for Rosie? Why so
many? How do they work? Any precautions for their use?
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5 Which one(s) of Rosies medication is/are not effective in terminating

acute asthma attacks and why is that?
6 What will you teach Rosie about each of the inhalers, use of MDIs, and
about using them in combination?
7 What will you teach Rosie to help reduce the number of candidal throat
infections?
8 Why does Rosie develop palpations, nervousness and restlessness with
increased dosage of the inhalers?
9 Rosies ABGs are significantly altered when she is diagnosed with
emphysema. What are the mechanisms of hypoxemia responsible for her
altered blood gases?
10 What do Rosies symptoms and diagnostic results tell you about the
severity of her emphysema?
11 Why does Rosie have a barrel chest?
12 Why is Rosie doing pursed lip breathing? How is it ultimately helping her
oxygenation?
13 Rosie is given 2 L/min of oxygen, why not 5 or higher levels of oxygen?
14 What is the most likely reason for Rosie developing such severe
bronchospasm when she received propranolol? Explain.
15 Rosie was careful to get her yearly flu shot. Although this is important
for all high risk groups, what in particular places Rosie at high risk for
developing influenza and why is it important for her to prevent getting
the flu? How does the influenza immunization prevent influenza?

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