A 24-year-old woman with a history of asthma complains of worsening chest tightness and cough. She currently has an albuterol inhaler that she uses as needed, but says that it does not help very much. She has no other medical problems and takes no other medications. The physical examination is unremarkable.
Which of the following is the most appropriate next step in management?a. Add an inhaled corticosteroid
Education about proper use of inhalers. Education is truly a cornerstone of asthma therapy. Patients should be educated about how to properly use their inhaler, how to monitor their pulmonary function (with peak expiratory flow), and how to recognize and avoid triggers. Proper education about inhalers includes shaking the medication before use, correct positioning, taking a slow deep breath while administering the medication, and holding the medication within the lungs for at least 5 seconds before breathing out. In addition to the importance of technique, patients should also be educated about the timing of use. Patients that know that they will be experiencing a trigger should use the inhaler 10 minutes in advance (e.g., used before exercise). As a general rule, the correct answer on the shelf examination usually follows the principle that the least invasive maneuver should be attempted first, and therefore choices such as obtaining a further history and patient education are usually the right answers. (A) An inhaled corticosteroid is the next step in therapy for worsening symptoms, however an additional medication might be avoided in this patient if she begins to use her inhaler correctly. (B) An inhaled anticholinergic such as ipratropium can be used to improve delivery of the β2 agonist reliever medications and improve bronchodilation, but this is not the next step. (D) Medication compliance and proper technique should be addressed before assuming that the diagnosis of asthma is incorrect.