Treatment Devices for an Asthma and Allergic Rhinitis Patient with Arthritis and Stroke

Author: V. Dimov, M.D., Fellow, Creighton University Division of Allergy & Immunology
Reviewer: S. Randhawa, M.D., Fellow, LSU (Shreveport) Department of Allergy & Immunology
Faculty Adviser: A. Bewtra, M.B.B.S., Associate Professor, Creighton University Division of Allergy & Immunology

A 58-year-old male with asthma and allergic rhinitis is seen for a follow-up at the allergy clinic. He only uses Albuterol PRN when he has wheezing in the course of upper respiratory tract infections. He was recently treated for acute pharyngitis and bronchitis with a 10-day course of Augmentin but still complains of nasal congestion. There is no nasal discharge, fever, chills or productive cough.

PMH:
DM2, allergic rhinitis, mild asthma, severe arthritis of the hands, R hand weakness secondary to remote stroke

Medications:
Nasacort (triamcinolone), Albuterol MDI, glyburide, rosiglitazone

Physical examination:
VSS
HEENT: Pale boggy turbinates with 75% obstruction of the nasal cavity
Chest: CTA (B)
CVS: Clear S1S2
Abdomen: Soft, NT, ND, +BS
Extremities: severe arthritis of both hands, and a R hand weakness secondary to remote stroke


A hand with arthritic changes. Image source: Cicadas, a Creative Commons license.

Laboratory results:
A CXR done by the PCP 5 days ago was negative.

What is the next step in the management?
The technique of use of the nasal spray and Albuterol inhaler was reviewed. Due to his arthritis and past stroke, the patient had a significant difficulty in using the devices correctly. He found it very difficult to push the activation parts of both theNasocort spray and the Albuterol inhaler. He was not able to point the nasal spray towards the ipsilatereal ear.

What would you recommend for this patient?
The Nasacort (R) spray was replaced with a Veramyst (R) spray which is activated by a squeezing button on the side of the device.

His Albuterol MDI was fitted with a VentEase (R) assist device and an AeroChamber (R).

The patient found the new devices much easier to use.

Final diagnosis:
Medication noncompliance secondary to difficulty in using the asthma and allergic rhinitis treatment devices due to a neuromuscular impairment.

What did we learn from this case?
Assist devices should be considered in patients with severe arthritis, stroke or other neuromuscular impairment who need to use asthma inhalers or nasal sprays. The standard devices and technique may not be sufficient in those patients, and therefore, may lead to poor treatment results.

References:
Aerosol Delivery Devices for the Geriatric Population. Helen M. Sorenson, MA, RRT, CPFT, American Association for Respiratory Care (PDF).
Modification of the spacer device. Use in the patient with arthritis or an artificial airway. Chest, Vol 102, 1243-1244, 1992.
Using an AeroChamber With Inhaled Medication. National Jewish Health.

Published: 08/12/2008
Updated: 09/25/2008