NURS 504 Week 2 Asthma Case Study Analysis Example

Asthma Case Study Analysis: Moving a Child-Care Worker From a Rescue Inhaler Alone to Budesonide-Formoterol as Maintenance and Reliever

Case Summary

The patient is a 41-year-old child-care worker with asthma since childhood. For the past three months the patient has used an albuterol inhaler four to five days a week, wakes at night with cough and wheeze about once a week and finished a five-day course of oral prednisone for an exacerbation six months ago. A fluticasone inhaler prescribed two years ago was stopped after a few months because of cost. The patient also reports a constantly stuffy nose and sneezing in spring and fall, has never smoked and works with toddlers who often have colds. Spirometry today shows an FEV1 of 72% of predicted with a 15% improvement after bronchodilator. The patient's only medication is albuterol, two puffs as needed.

Assessment

Using the control questions of the Global Initiative for Asthma (Global Initiative for Asthma [GINA], 2025) for the past four weeks, this patient answers yes to every item: symptoms on most days, waking at night, the rescue inhaler needed most days, and asthma getting in the way at work, which places the asthma in the uncontrolled category. The patient also has risk factors for future exacerbations: an exacerbation needing oral corticosteroids in the past year, a low FEV1, no inhaled corticosteroid, and frequent exposure to respiratory viruses. Allergic rhinitis is likely and, if untreated, can worsen asthma control. The pattern is the one current guidance was rewritten to prevent: frequent rescue use with no anti-inflammatory treatment at all.

Why a Rescue Inhaler Alone Is Not Enough

The airways in asthma stay inflamed between attacks, and albuterol, a short-acting beta-2 agonist, relaxes airway smooth muscle without treating the inflammation (Burchum & Rosenthal, 2019). GINA (2025) no longer recommends treatment with a short-acting beta agonist alone for adults and adolescents, because regular reliance on it without an inhaled corticosteroid is associated with more severe exacerbations and asthma deaths. The patient's frequent albuterol use is therefore a marker of risk, not a solution.

Other Conditions to Consider

Before settling on the plan, the analysis should consider what else could be contributing. Vocal cord dysfunction, chronic rhinosinusitis, gastroesophageal reflux and obesity can all mimic or worsen asthma, and the patient's improvement after bronchodilator supports asthma as the main diagnosis. The workplace deserves attention as well: a child-care center exposes the patient to frequent viral infections, cleaning products and, in some centers, mold or pets in classrooms, any of which can trigger symptoms. Asking whether symptoms improve on weekends and vacations helps separate work-related triggers from seasonal allergy. Finally, the patient should be asked about aspirin or other anti-inflammatory drugs, since a small share of adults with asthma, especially those with nasal symptoms, react to them with severe bronchospasm.

Pharmacologic Plan

Budesonide-Formoterol as Maintenance and Reliever

The recommended treatment is low-dose budesonide-formoterol 160/4.5 mcg used as both daily maintenance and as-needed reliever therapy. A practical regimen for this adult is one inhalation twice daily plus one inhalation whenever symptoms occur, not exceeding the total daily inhalations stated in the GINA report and product information. This approach corresponds to GINA Step 3 on its preferred track and to the 2020 NAEPP focused update, which recommends single maintenance and reliever therapy for people aged 12 and older with moderate persistent asthma (Cloutier et al., 2020). In the United States, using the combination as a reliever is off-label, though endorsed by both guidelines.

Budesonide is an inhaled corticosteroid that suppresses airway inflammation by reducing inflammatory cell recruitment and cytokine production. Formoterol, though it lasts about 12 hours, begins opening the airways within minutes, which is why it can relieve symptoms nearly as fast as albuterol (Burchum & Rosenthal, 2019). Because each reliever dose also delivers budesonide, the patient receives more anti-inflammatory treatment on bad days, when inflammation is rising. A long-acting beta agonist should never be used without an inhaled corticosteroid in asthma, and the combination inhaler guarantees they are taken together.

The evidence for this regimen is strong. In a meta-analysis of randomized trials, Sobieraj et al. (2018) found that among about 22,500 patients aged 12 and older, the single-inhaler approach cut exacerbation risk by roughly a third relative to taking a matched dose of the two drugs on a fixed schedule and relying on a separate short-acting inhaler for symptoms.

Cost and Access

Because cost ended the patient's last controller, the plan must address it directly. A generic budesonide-formoterol inhaler is available, and the nurse should check the patient's insurance formulary and manufacturer or pharmacy assistance programs before the patient leaves. One inhaler for both purposes may also cost less than separate controller and rescue inhalers.

Allergic Rhinitis

An intranasal corticosteroid such as fluticasone propionate nasal spray, two sprays in each nostril daily, treats the likely allergic rhinitis, and better control of the nose often improves asthma control (Wells et al., 2018). The patient should expect the nasal spray to need a week or so of daily use before the full benefit shows.

Albuterol

The albuterol inhaler is no longer needed as the regular reliever, since budesonide-formoterol replaces it. Some clinicians leave a small supply for exercise or for confusion during the transition, but the patient should understand that the combination inhaler is now the reliever.

Nonpharmacologic Measures

The patient should receive an annual influenza vaccine and stay current with other recommended vaccines, wash hands often at work, and identify allergen triggers such as pollen seasons. Inhaler technique should be checked at this visit, ideally by having the patient demonstrate it, and a written action plan should spell out the steps for a bad day and the danger signs that mean going straight to an emergency department.

Monitoring and Adverse Effects

Control should be reassessed in two to three months, sooner if symptoms persist, using symptom questions, reliever use and exacerbations, and spirometry should be repeated to see whether lung function improves. If asthma is well controlled for about three months, the dose can be reviewed for stepping down. Adverse effects of budesonide include oral candidiasis and hoarseness, reduced by rinsing the mouth and spitting after maintenance doses. Formoterol can cause tremor, palpitations and, uncommonly, low potassium at high doses (Burchum & Rosenthal, 2019). The patient should report any need for more than the maximum daily inhalations, which signals a worsening that needs prompt review.

Patient Education

The patient should be able to explain, in their own words, that the inhaler is taken twice daily even when well and used as needed for symptoms, how to recognize worsening asthma, the maximum number of inhalations in a day, and when to call the clinic or seek emergency care. Teach-back is especially important because the regimen differs from the old pattern of a controller and a separate rescue inhaler.

Teaching Points for Nursing Students

As a nurse educator, I would use this case to teach three points. First, frequent rescue inhaler use is a red flag, not a sign that the patient is coping. Second, the shift in guidance away from short-acting beta agonist monotherapy is one of the most important recent changes in respiratory pharmacology, and students should learn to question an order for albuterol alone. Third, a regimen fails if the patient cannot afford it or use the device correctly, so cost and technique belong in every plan.

References

Burchum, J. R., & Rosenthal, L. D. (2019). Lehne's pharmacology for nursing care (10th ed.). Elsevier.

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

Global Initiative for Asthma. (2025). Global strategy for asthma management and prevention (2025 update). https://ginasthma.org/reports/

Sobieraj, D. M., Weeda, E. R., Nguyen, E., Coleman, C. I., White, C. M., Lazarus, S. C., Blake, K. V., Lang, J. E., & Baker, W. L. (2018). Association of inhaled corticosteroids and long-acting beta-agonists as controller and quick relief therapy with exacerbations and symptom control in persistent asthma: A systematic review and meta-analysis. JAMA, 319(14), 1485-1496. https://doi.org/10.1001/jama.2018.2769

Wells, B. G., DiPiro, J. T., Schwinghammer, T. L., & DiPiro, C. V. (2018). Pharmacotherapy handbook (10th ed.). McGraw-Hill Education.