NUR 7071 Module 3 Asthma Case Paper: Moving an Adult Off Albuterol Alone With As-Needed ICS-Formoterol Example

Not Just the Blue Inhaler: Bringing an Inhaled Steroid Into Mild Asthma Care

Student Name

M.S. in Nursing, Family Nurse Practitioner, Thomas Edison State University

NUR-7071: Adult Primary Care Part I

Mentor Name

Month Day, Year

Not Just the Blue Inhaler: Bringing an Inhaled Steroid Into Mild Asthma Care

The Patient

Aisha Coleman, an invented 27-year-old daycare teacher, was diagnosed with asthma at age 9. She uses an albuterol inhaler three or four days a week, especially during cold weather and when children in her room have colds, and wakes coughing about twice a month. Last winter she went to urgent care once and received a five-day course of prednisone. She has no other controller medication; she stopped a daily inhaled steroid years ago because she "felt fine." She lives with a cat, works around frequent viral infections and has mild allergic rhinitis. Her lungs are clear today, and her peak flow is 82 percent of her personal best.

Assessing Control and Severity

Spirometry before and after a bronchodilator showed an FEV1 of 84 percent predicted, rising 14 percent after albuterol, confirming reversible airflow obstruction. Her Asthma Control Test score was 17, indicating poorly controlled asthma. Using the national guidelines' categories, symptoms several days each week with night waking about twice monthly suggest mild persistent asthma; her urgent care visit and steroid course are a further warning sign. In the language of the GINA strategy, she has uncontrolled symptoms and at least one risk factor for future severe exacerbations.

Why Albuterol Alone Is No Longer Enough

Reddel et al. (2022) summarize the reasoning behind the 2021 GINA strategy. Relying on a short-acting beta agonist alone, without any inhaled corticosteroid, is associated with higher risk of severe exacerbations and asthma death, and heavy reliever use without anti-inflammatory treatment can mask worsening inflammation. GINA therefore recommends that adults and adolescents receive inhaled corticosteroid-containing treatment at every step. Its preferred approach, called Track 1, uses low-dose budesonide-formoterol as the reliever: taken as needed alone at steps 1 and 2, and as both maintenance and reliever at steps 3 to 5. The rationale is that each time a patient reaches for relief, she also receives a dose of anti-inflammatory medicine.

Evidence From a Trial

O'Byrne et al. (2018) randomly assigned 3,849 people with mild asthma to one of three regimens: placebo twice daily with terbutaline for relief, budesonide-formoterol only when needed or twice-daily budesonide plus as-needed terbutaline for 52 weeks. Symptom control was better with the combination reliever than with terbutaline alone, though less than daily budesonide. It lowered the rate of severe flares by roughly 64 percent relative to terbutaline alone, a reduction similar to that seen with daily budesonide, while exposing patients to far less inhaled steroid, roughly a sixth of the daily-maintenance dose.

The United States Guidance

Cloutier et al. (2020) updated six topics in the national guidelines. For people 12 and older with mild persistent asthma at step 2, the update allows either a low-dose inhaled corticosteroid every day plus albuterol when needed or as-needed use of an inhaled corticosteroid together with albuterol. For moderate-to-severe persistent asthma at steps 3 and 4, it prefers using one inhaled corticosteroid-formoterol inhaler both daily and for relief. It also addressed long-acting muscarinic antagonists as an add-on, allergen mitigation, immunotherapy and the role of fractional exhaled nitric oxide testing.

Why Not Simply Restart a Daily Steroid?

A daily low-dose inhaled steroid with albuterol as needed is also an accepted step 2 option, and it is what Ms. Coleman used years ago. She stopped it because she felt well, a common pattern: adherence to daily controllers in mild asthma is low, which leaves patients relying on albuterol alone between flares. An as-needed combination inhaler links anti-inflammatory treatment to the moments she actually feels symptoms, which fits how she uses medicine.

Plan

After discussing options, Ms. Coleman chose budesonide-formoterol 160/4.5 mcg, one puff whenever symptoms appear, within a set daily limit, replacing albuterol for routine relief. I explained that in the United States this as-needed use follows the GINA strategy but is not the product's labeled use, and confirmed her insurance coverage. If cost had been a barrier, an inexpensive inhaled corticosteroid taken whenever she used albuterol would have followed the national update's step 2 option.

Teaching and Self-Management

I watched her use the new inhaler and corrected two errors: she was not exhaling fully before inhaling and was not holding her breath afterward. We completed a written asthma action plan with peak flow zones and clear instructions on when to seek urgent care. We discussed limiting the cat to areas outside her bedroom and using a saline rinse and intranasal steroid for rhinitis, which can worsen asthma control.

Vaccines and Prevention

She received her annual influenza vaccine. Because asthma counts as chronic lung disease, she is also eligible for a pneumococcal vaccine, which was given, and she is up to date on COVID-19 vaccination. Working with young children exposes her to frequent infections, so hand hygiene and early use of her reliever during colds were included in her action plan.

Follow-Up

She is booked for a visit in about a month to review her Asthma Control Test, reliever use and technique. If she still needs relief more than a few times a week, the next step is maintenance-and-reliever therapy with the same inhaler. Spirometry will be repeated within a year.

Limits

The O'Byrne trial was sponsored by the manufacturer and enrolled patients with mild asthma, many of whom had well-controlled symptoms at the start. GINA and the national guidelines differ, and insurance coverage for as-needed use varies. The patient is invented.

Conclusion

Reddel and colleagues explained why albuterol alone is no longer recommended for adults, O'Byrne and colleagues showed that as-needed budesonide-formoterol reduces severe attacks while using little inhaled steroid and Cloutier and colleagues offered national options for the same step. Replacing her reliever with one that treats inflammation, correcting her technique, writing an action plan and planning a step up if needed give Ms. Coleman protection she lacked.

References

Cloutier, M. M., Baptist, A. P., Blake, K. V., Brooks, E. G., Bryant-Stephens, T., DiMango, E., Dixon, A. E., Elward, K. S., Hartert, T., Krishnan, J. A., Lemanske, R. F., Ouellette, D. R., Pace, W. D., Schatz, M., Skolnik, N. S., Stout, J. W., Teach, S. J., Umscheid, C. A., & Walsh, C. G. (2020). 2020 focused updates to the asthma management guidelines: A report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. Journal of Allergy and Clinical Immunology, 146(6), 1217-1270. https://doi.org/10.1016/j.jaci.2020.10.003

O'Byrne, P. M., FitzGerald, J. M., Bateman, E. D., Barnes, P. J., Zhong, N., Keen, C., Jorup, C., Lamarca, R., Ivanov, S., & Reddel, H. K. (2018). Inhaled combined budesonide-formoterol as needed in mild asthma. New England Journal of Medicine, 378(20), 1865-1876. https://doi.org/10.1056/NEJMoa1715274

Reddel, H. K., Bacharier, L. B., Bateman, E. D., Brightling, C. E., Brusselle, G. G., Buhl, R., Cruz, A. A., Duijts, L., Drazen, J. M., FitzGerald, J. M., Fleming, L. J., Inoue, H., Ko, F. W., Krishnan, J. A., Levy, M. L., Lin, J., Mortimer, K., Pitrez, P. M., Sheikh, A., . . . Boulet, L.-P. (2022). Global Initiative for Asthma strategy 2021: Executive summary and rationale for key changes. European Respiratory Journal, 59(1), Article 2102730. https://doi.org/10.1183/13993003.02730-2021