Asthma management Case Study

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Asthma management Assignment

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Introduction

Analysis of case study is a task that helps analyse the situation and determine the type of issue. After determining the problem, people develop best strategies for accomplishing desired outcomes. Case study analysis helps to bring an understanding of complex issues as well as extends experience towards existing knowledge by previous research. This assignment is going to do a case study analysis. For this, it has formulated a case study on an asthma patient who is suffering from an uncontrolled asthma issue. This assignment will critically analyse the information provided in the case of study, for example, whether the treatment approaches are appropriate or not and whether provided medications are proven beneficial for this patient. The thesis statement of this essay is to critically analyse the case study with help of existing literature. Additionally, it will use theories and healthcare practices to support the discussion and demonstrate the asthma management provided in the case study to promote patients' health. Lastly, this study will accurately establish the analysing technique regarding discussing asthma management. 

Asthma management in normal, complex and unpredictable context

Asthma is a medical condition where airways swell, narrow, and produce extra mucus. This study is based on a patient who is suffering from uncontrolled asthma. According to the case study, this patient has experienced an acute asthma attack 6-months ago. From that incident, her doctor prescribed a combination of budesonide and formoterol for six months before she came to the hospital for a further check-up. Additionally, doctors prescribed her bronchodilators, Theophylline, and Leukotriene modifiers. Based on the case study and its treatment approaches, this section will now discuss them with help of existing literature.

Asthma management

The case study has mentioned that the patient has an uncontrolled asthma problem, and six months ago, she experienced an acute asthma attack. Hence, it can be discussed that Mrs Y has moderate persistent asthma. That is why her doctor prescribed several treatment approaches such as bronchodilators, Leukotriene modifiers, inhaled corticosteroids, and theophylline. Capstick and Elsey (2021) Asthma is one ofsevere medical condition affecting around 5.4 million individuals in UK, including children and adults. Asthma attacks can happen at random with no clear precipitating factors or cause by poor connection with treatment. It is a life-long condition, which, if treated effectively, can be successfully controlled to achieve resolution of asthma symptoms. According to this scholar, uncontrolled asthma can be managed by taking effective approaches such as inhaler technique, the combination of budesonide and formoterol.

This scholar also stated that a combination of budesonide and formoterol could be given in three distinct doses: low, medium, and high. In low dose quantities of medicine will be 160/4.5 µg; in medium dose, quantity will remain the same. Only the two puffs twice a day need to be taken, and lastly, for high doses, the quantity will be 320/9 µg of two puffs twice a day. Additionally, Caminati et al. (2021) stated that utilisation of single ICS (infrequent inhaled corticosteroid)/LABA (short-acting beta-agonists) inhalers are utilised regularly twice or once a day, with the additional dose used for providing immediate relief of symptoms. Moreover, Price et al. (2014) explained that anti-IgE therapy is an effective treatment for uncontrolled asthma. Zervas et al. (2018) elaborated that tiotropium can be used for treatment of uncontrolled asthma. It is a LAMA (long-acting muscarinic antagonist), and it has inflammatory effects. It has the potential for improving asthma control, including bronchodilation. This scholar has also agreed that Anti-IgE treatment or omalizumab is an efficient treatment approach for selected health issues.

The provided case study has shown that Mrs Y was treated with a combination of budesonide and formoterol; additionally, doctors have prescribed her anti-IgE therapy. Based on the existing information, it has been discussed that doctors have considered appropriate treatment approaches for the patient. However, existing literature stated that, in case of uncontrolled asthma, doctors could also consider ICS/LABA inhalers and LAMA therapy; hence, in the future, doctors can consider these two treatment approaches for Mrs Y to improve her health condition. Papi et al. (2020) illustrated that GINA (Global Initiative for Asthma guidelines) had proposed some pharmacological approaches based upon controller treatment with the SABA strategies. This can be considered a rescue intervention for uncontrolled asthma. This scholar has also agreed to the previously stated treatment approaches. In other words, this scholar also believes that ICS/LABA therapy is a beneficial treatment approach for uncontrolled asthma. Addition of ICS with LABA can reduce mild and severe asthma exacerbation rates. According to the Global Initiative for Asthma guidelines (2021), LAMA is appropriate for people with mild to moderate levels of asthma as well. Regarding modest improvement in condition, doctors can use ICS/LABA with LAMA. This composition helps in exacerbation reduction and lung function improvement.

Zervas et al. (2018) explained that Oral corticosteroids (OCS) could be another treatment approach for uncontrolled asthma. According to this scholar, OCS is extremely variable as OCS is also highly variable. OCS is mainly used for patients with severe asthma and has several side effects; some potential examples of OCS utilisation are diabetes, obesity, pneumonia, and hypertension. Hence, it can be discussed that OCS therapy would not be appropriate for Mrs Y, although she has uncontrolled asthma because she has mild to moderate levels of asthma. OCS is mostly beneficial for severe asthma patients. The case study also suggested that Mrs Y takes thyroid hormones to treat her thyroiditis. Bingyan and Dong (2019) explained that patients' clinical studies showed several non-thyroid diseases (heart failure and respiratory issues) change within thyroid hormones. According to this scholar, levels of thyroid hormones are the key factors within severe exacerbation of bronchial asthma.Additionally, levels of thyroid hormones in older patients have severe exacerbation of asthma recommends that both hypothyroidism and acute exacerbation are reversible and short. In this regard, Gong et al. (2017) explained that Hyperthyroidism might cause asthma to worsen. However, since this patient has thyroiditis, this is not clear that having thyroid hormone for this consideration may affect the patient.

It has been previously discussed that the doctor of Mrs Y has prescribed her some appropriate medications for uncontrolled asthma. According to the case study, doctors have prescribed her theophylline, a phosphodiesterase inhibiting medicine used to treat respiratory diseases such as asthma. This medicine helps to open and relax air passages within the lungs and make it easier for breathing. Rogliani et al. (2019) has conducted research to identify the effectiveness of doxofylline and theophylline. The study has determined that theophylline is more effective fordecreasing daily asthma attacks and helps prevent risk of adverse effects.

Conversely, Jilani et al. (2021) argued that asthma treatment with theophylline is not suggested from present clinical practice guidelines such as GINA. Hence, doctors of Mrs Y could consider some other drugs to treat her asthma instead of theophylline. Following prescribed medication was Leukotriene modifiers, which work as leukotriene-related enzyme inhibitors. This can help for preventing breathing problems. Montuschi (2010) has elaborated that Leukotrienes has a critical pathophysiological role in asthma, specifically in subgroups of asthma patients. According to this scholar, Leukotriene modifiers give therapeutic alternatives towards inhaled glucocorticoids in patients having persistent-mild asthma. Moreover, patients who have severe asthma can use this medication for improving asthma control.

Marcello and Carlo (2016) explained that leukotriene (LT) has a significant role in bronchial asthma pathogenesis. This scholar also explained that leukotriene is better than a placebo. It is effective as antihistamines; however, this is less efficientas compared to nasal corticosteroids to improve symptoms and QoL (Quality of Life) within patients who have uncontrolled asthma issues. In addition, Kaplan et al. (2020); Montuschi and Peters?Golden (2010) agreed with other scholars and explained that leukotriene effectively reduces late and early asthmatic responses that are increased by the allergen inhalation. Unlike budesonide, leukotriene inhibits maximum initial asthmatic response; however, both medicines attenuate the last asthmatic response.

Additionally, anti-LTs can decrease allergen-induced Airway hyper responsiveness towards a lower extent as compared to inhaled corticosteroids. Moreover, these scholars stated that ICS is considered an efficient long-term controller for managing asthma. However, they have also explained that if asthma remains uncontrolled despite moderate-dose ICS, inducing ICS dose could not be beneficial because of high risk of systemic and local opposite effects and that is why most of the healthcare professional consider low-dose ICS to treat asthma patient. This is a practical treatment approach for asthma patients, and doctors of Mrs Y had considered this for improving hair condition; thus, it can be stated that by prescribing this medication, doctors effectively manage the health of Mrs Y.

Techniques of analysis and treatment

Asthma is one of the heterogeneous diseases that is categorised by severe airway inflammation. It is a severe global health problem, which affects every age group, and throughout the world, approximately 339 million people suffer from asthma. The above section discusses asthma management in normal or complex contexts, and it has critically analysed the treatment approaches stated in the provided case study. This section will now discuss the treatment techniques in asthma management with the help of existing literature and healthcare-related theories.

Research has suggested that different techniques can treat asthma by considering the level, and these are discussed below.

Medications

Medications for asthma can be distinguished into two different categories such as long-term control and quick-relief medications. A detailed discussion has been provided below.

Long-Term Control Medications

Long-term medications have inflammatory components such as corticosteroids and leukotriene modifiers, and these medications are taken daily for reducing tightening and swelling in airways. Some of the long-term medications are stated below.

Corticosteroids

Corticosteroids are still the most effective and potent anti-inflammatory agents that are available regarding asthma management. Corticosteroids are always valuable for treating every kind of persistent asthma within patients of every age group. Quirt et al. (2018) elaborated that regarding long-term utilisation, inhaled corticosteroids are used over other oral steroids as inhaled substances have some systemic adverse effects. Therapy of oral steroids is regarding long-term control, and it is utilised for treating refractory, persistent, and severe asthma. The case study has shown that Mrs Y was treated by inhaled corticosteroid because she has uncontrolled asthma. This long-term control approach can decrease airway inflammation and prevent asthma attacks because she had an acute asthma attack six months ago. In this regard, Barnes (2010) and Alangari (2014) stated that corticosteroid has a vital role in treating severe asthma exacerbation.

Regarding this asthma treatment, approach one healthcare theory can be applied is Orem’s Self-Care Deficit Nursing Theory. This theory defines the act of assisting other people in management and provision of self-care for maintaining human function at home level effectiveness (Gligor and Domnariu, 2020). Based on the idea of this theory, it can be stated that the nurses helped Mrs Y take care of, appropriately taking correct medications on time.

Nedocromil

The next medication for long-term control is nedocromil, a safe agent with low to medium anti-inflammatory effects. This medicine inhibits late and early-phase asthmatic responses towards allergens as well as exercise. This drug appears to be more effective as compared to other long-term medications for inhibiting bronchospasm influenced by cold air, exercise, and provocative testing. Calhoun et al. (2012); Asplund (2013) explained that asthma could be controlled by nedocromil, which is effective for long-term control. According to the Asthma management framework World Health Organisation (WHO), they are taking action regarding extended diagnosis and treatment of asthma. WHO has developed PEN (Package of Essential Noncommunicable disease interventions) to improve asthma patients' health (World Health Organisation, 2021). This disease intervention approach includes protocols regarding assessment, diagnosis, as well as management of severe respiratory disease such as asthma, additionally, it modules upon healthy lifestyle counselling such as self-care and tobacco cessation. Hence, in the case of Mrs Y, they can consider this intervention plan; however, doctors did not prescribe this medication to Mrs Y. Since researchers considered this medication as safe and effective for long-term control, the healthcare professional could also use this for improving the condition of Mrs Y.

Salmeterol

Another effective long-term control medication is salmeterol, and it is the long-acting beta-agonist. Action mechamism of this drug and its side effects are similar towards other beta-agonists. Information has suggested that beta-agonists are generally used for quick-relief; whereas, salmeterol is worked as the long-term control and should be utilised as the single-agent regarding long-term control; however, it should be utilised by combining with ICS or any other anti-inflammatory components. In this context, Adams and Nguyen (2020) argued that salmeterol has common side effects such as upper respiratory infection, oral candidiasis, headaches, cough, bronchitis, and vomiting. Additionally, people with severe respiratory diseases such as asthma can experience pneumonia, dysphonia and throat irritation. In addition, Bousquet et al. (2017) explained that besides using salmeterol with ICS, healthcare practitioners could also use FP (fluticasone propionate) because it has proven beneficial for controlling asthma. Instead of using both these medications individually, a combination of these two will be more effective. Hence, it can be discussed that, in the case of Mrs Y, instead of using ICS alone, doctors could consider the combination of salmeterol and ICS to get better results.

Theophylline

In current times, theophylline is used as a second or third-line agent as it has several adverse effects and has the potential to interact with other drugs. Currently, this medication is used for patients who show nocturnal asthma symptoms, which other high-dose anti-inflammatory medications could not control. According to Barnes (2013), theophylline is the most widely prescribed medicine to treat asthma; however, it has several adverse effects: headache, diarrhoea, trouble sleeping, restlessness, irritability, shaking, and nervousness. According to the case study, doctors had prescribed Mrs Y theophylline; however, existing information highlighted many side effects. Nowadays, it is not used as a first-line medication for asthma.

Additionally, in 2019, GINA's Asthma Management and Prevention Report stated that theophylline has a high risk of opposite effects, and healthcare organisations can use oral SABA and inhaled SABA instead of it. Additionally, it has a high potential to increase the events of fatal abnormalities and currently, the clearance of this medicine has been reduced. Hence, it can be discussed that several effective and less side effect medicines are present regarding asthma and doctors of Mrs Y could consider one of them so that they can prevent her from the impact of those adverse effects. Additionally, the case study has shown that Mrs Y has thyroiditis, and research has found that patients who have Hashimoto's thyroiditis can lead to hypothyroidism, where metabolism of theophylline is decreased. Thus, doctors need to increase the dose of theophylline (Kavanagh and Boparai, 2015). Since theophylline has a high risk of adverse effects, this incident could substantially negatively affect her health. Hence, it can be discussed that this particular treatment approach is not appropriate for Mrs Y, and it can have a significant adverse effect on her health.

Quick-Relief Medications

SABA (Short-Acting Beta Agonists)

SABA is an agent of choice to relieve bronchospasm as well as prevent exercise-induced bronchospasm. Regarding SABA, some selective beta-agonists are preferred to non-selective beta-agonists: bitolterol, albuterol, pirbuterol, and metaproterenol. The reason for this preference is that selective agents have a few cardiovascular side effects compared to non-selective agents and their action duration is longer. Nwaru et al. (2020); Silva and Jacinto (2016) explained that over utilisation of SABA can indicate adverse health outcomes and poor asthma control. These scholars argued that over utilisation of SABA is increasing, and it is worrisome because these medicines cannot address underlying inflammatory pathology, which gives rise to worsening symptoms (Nwaru et al. 2020).

Regarding this medicine, the GINA report shows that they no longer suggest intervention with SABA alone because it cannot protect against serious asthma exacerbations. The regular use of SABA can increase the risk of having different side effects (Global Initiative for Asthma guidelines, 2021). Additionally, these scholars elaborated that this medication is as a single therapy or combined with ICS; excessive use of SABA is associated with an increased risk of asthma exacerbation. Moreover, by agreeing to other scholars, Billington et al. (2017) and Chin et al. (2017) stated that these drugs are not appropriate for the treatment of asthma as several safety issues are connected to it. It can lead to a black-box warning by suggesting that regular or excessive use of SABA should not be utilised alone for asthma patients. Hence, it can be discussed that Mrs Y has taken the appropriate decision not to use SABA as quick-relief medicine because it can affect her health negatively.

Systemic corticosteroids (SC)

The last quick-relief medication is Systemic corticosteroids, and it is helpful to gain initial control of asthma. This therapy is used to treat moderate to severe asthma exacerbation. Price et al. (2020) and Bleecker et al. (2020) stated that SC, both injectable, oral drugs, effectively resolve severe asthma symptoms. Like SABA, this quick-relief medication also causes significant adverse outcomes regarding patients. Regarding quick-relief, SC is a very effective and fast-acting option regarding a resolution of severe asthma symptoms. This study has highlighted that GINA has recommended SC regarding short-term course treatment of acute exacerbation (Price et al. 2020). Hence, it can be discussed that doctors could use SC for Mrs Y because she experienced an asthma attack, and for an emergency incident, she could prescribe her SC to mitigate any type of severe asthma exacerbation.

Self-management of the person with asthma

After studying the case study of Mrs Y, as a healthcare professional, I am providing some self-management strategies for Mrs Y, which can help her, manage her asthma issue in the future. These strategies are stated below.

Providing her self-management education regarding asthma

Lastly, I can state that medical professionals can give her self-management education by considering my professional role. They can tell her to make a self-management plan that will include intervention for normal levels of asthma, intervention when asthma gets worse and emergency action. This entire plan will allow her to be aware of her condition. If anything gets wrong, she can consider those interventions and take proper initiatives to manage her asthma. According to Lung Association (2020), self-management can help patients feel confident while monitoring their symptoms and it allows them to use their asthma medication correctly. Moreover, this approach can help patients to reduce their exposure to asthma exposure. Hence, professionals can make her aware of the importance of self-management for asthma so that when she is at home, she can manage her health without taking professional help.

Encouraging quitting smoking and managing stress

Case study has shown that Mrs Y has a smoking habit, and studies have found that smoking can worsen asthma because it makes the airways narrow (Asthma UK, 2021). Hence, I can suggest that she quit smoking and lower the risk of severe asthma attacks. Regarding this asthma prevention, one of health promotion and prevention theories can be applied, such as Health Belief Model. This model is used for guiding disease prevention and health promotion. It has been used for predicting and explaining changes within health behaviours (Jones et al. 2015). By considering this theoretical model and understanding her medication condition, I can state that smoking cessation behaviour will be a sabbatical self-management strategy to manage her asthma. Since she experienced a severe asthma attack in the past, it is usual that she might have stress and information have suggested that stress works as asthma triggers (Asthma UK, 2021). Hence, regarding self-management, Mrs Y can manage her stress by doing some meditation, exercise, and social gatherings. 

Suggesting some exercise to control asthma

Freeman et al. (2020); Dogra et al. (2011) explained that some exercises are present related to asthma control. By doing these exercises regularly, people can control their asthma and manage their asthma. In this context, I can consider Social Cognitive Theory (SCT). It defines the influence of people's experiences, others' actions, and environmental factors on people's health behaviour. This theory gives opportunities regarding social support by installing self-efficacy and expectations (Rhee et al. 2018). By considering this theory, I can suggest that Mrs Y can do some asthma-related exercise by taking help of people who are also suffering from asthma. By this approach, she will get social support and help her manage her stress and asthma.

Conclusion

This essay has aimed to critically describe the treatment care of an individual living with asthma by utilising current evidence for supporting the discussion. It has formulated a case study, and with the help of existing literature, it has discussed whether the provided medications and treatment approaches are appropriate for the patient or not. It has concerned the information with the use of different Asthma Management frameworks by GINA and WHO. Additionally, it has elaborated self-management strategies for asthma patients so that they can take care of themselves without any professional help. From this discussion, it can be concluded that doctors had prescribed some medicines to Mrs Y. The majority of them are proven beneficial; however, theophylline was not appropriate for her as it has several adverse effects on her health. Thus, doctors could consider some other medication instead of theophylline. Lastly, since Mrs Y previously experienced a severe asthma attack, these self-management strategies could benefit her.

Reference list

Journals

Alangari, A.A., 2014. Corticosteroids in the treatment of acute asthma. Annals of thoracic medicine9(4), p.187.

Asplund, C., 2013. Is nedocromil sodium effective in preventing asthmatic attacks in patients with a history of asthma?. Evidence-Based Practice16(6), p.E2

Barnes, P.J., 2010. Inhaled corticosteroids. Pharmaceuticals3(3), pp.514-540.

Barnes, P.J., 2013. Theophylline. American journal of respiratory and critical care medicine188(8), pp.901-906.

Billington, C. K., Penn, R. B., and Hall, I. P. 2017. β2 Agonists. Handbook of experimental pharmacology237, 23–40.

Bingyan, Z. and Dong, W., 2019. Impact of thyroid hormones on asthma in older adults. Journal of International Medical Research47(9), pp.4114-4125.

Bleecker, E.R., Menzies-Gow, A.N., Price, D.B., Bourdin, A., Sweet, S., Martin, A.L., Alacqua, M. and Tran, T.N., 2020. Systematic literature review of systemic corticosteroid use for asthma management. American journal of respiratory and critical care medicine201(3), pp.276-293.

Bousquet, J., Barnes, N., Gibbs, M., Gul, N., Tomkins, S.A., Zhou, X., Cho, Y.J., Park, H.S., Busse, W. and Zhong, N., 2017. Asthma control using fluticasone propionate/salmeterol in Asian and non-Asian populations: a post hoc analysis of the GOAL study. BMC pulmonary medicine17(1), pp.1-12.

Calhoun, W.J., Ameredes, B.T., King, T.S., Icitovic, N., Bleecker, E.R., Castro, M., Cherniack, R.M., Chinchilli, V.M., Craig, T., Denlinger, L. and DiMango, E.A., 2012. Comparison of physician-, biomarker-, and symptom-based strategies for adjustment of inhaled corticosteroid therapy in adults with asthma: the BASALT randomized controlled trial. Jama308(10), pp.987-997.

Caminati, M., Vaia, R., Furci, F., Guarnieri, G. and Senna, G., 2021. Uncontrolled Asthma: Unmet Needs in the Management of Patients. Journal of Asthma and Allergy14, p.457.

Capstick, T.G. D and Elsey, L., 2021. Uncontrolled asthma: assessment and management. The Pharmaceutical Journal. pp. 1-7

Chin, M.C., Sivasampu, S. and Khoo, E.M., 2017. Prescription of oral short-acting beta 2-agonist for asthma in non-resource poor settings: A national study in Malaysia. PloS one12(6), p.e0180443.

Dogra, S., Kuk, J.L., Baker, J. and Jamnik, V., 2011. Exercise is associated with improved asthma control in adults. European Respiratory Journal37(2), pp.318-323.

Freeman, A.T., Staples, K.J. and Wilkinson, T.M., 2020. Defining a role for exercise training in the management of asthma. European Respiratory Review29(156).

Gligor, L. and Domnariu, C.D., 2020. Patient Care Approach Using Nursing Theories-Comparative Analysis of Orem’s Self-Care Deficit Theory and Henderson’s Model. Acta Medica Transilvanica25(2), pp.11-14.

Gong, P.H., Dong, X.S., Li, C., Bao, J., Cao, Z.L., Yuan, Y., Zheng, Y.L. and Gao, Z.C., 2017. Acute severe asthma with thyroid crisis and myasthenia: a case report and literature review. The clinical respiratory journal11(6), pp.671-676.

Jilani, T.N., Preuss, C.V. and Sharma, S., 2021. Theophylline. StatPearls [Internet].

Jones, C.L., Jensen, J.D., Scherr, C.L., Brown, N.R., Christy, K. and Weaver, J., 2015. The health belief model as an explanatory framework in communication research: exploring parallel, serial, and moderated mediation. Health communication30(6), pp.566-576.

Kaplan, A., FitzGerald, J.M., Buhl, R., Vogelberg, C. and Hamelmann, E., 2020. Comparing LAMA with LABA and LTRA as add-on therapies in primary care asthma management. NPJ primary care respiratory medicine30(1), pp.1-11.

Kavanagh, S., and Boparai, P., 2015. Thyroid dysfunction and drug interactions. The Pharmaceutical Journal. pp. 1-6

Marcello, C. and Carlo, L., 2016. Asthma phenotypes: the intriguing selective intervention with Montelukast. Asthma research and practice2(1), pp.1-12.

Montuschi, P. and Peters?Golden, M.L., 2010. Leukotriene modifiers for asthma treatment. Clinical & Experimental Allergy40(12), pp.1732-1741.

Montuschi, P., 2010. Role of leukotrienes and leukotriene modifiers in asthma. Pharmaceuticals3(6), pp.1792-1811.

Nwaru, B.I., Ekström, M., Hasvold, P., Wiklund, F., Telg, G. and Janson, C., 2020. Overuse of short-acting β2-agonists in asthma is associated with increased risk of exacerbation and mortality: a nationwide cohort study of the global SABINA programme. European Respiratory Journal55(4).

Papi, A., Blasi, F., Canonica, G.W., Morandi, L., Richeldi, L. and Rossi, A., 2020. Treatment strategies for asthma: reshaping the concept of asthma management. Allergy, Asthma & Clinical Immunology16(1), pp.1-11.

Price, D., Castro, M., Bourdin, A., Fucile, S. and Altman, P., 2020. Short-course systemic corticosteroids in asthma: striking the balance between efficacy and safety. European Respiratory Review29(155).

Price, D., Fletcher, M. and Van Der Molen, T., 2014. Asthma control and management in 8,000 European patients: the REcognise Asthma and LInk to Symptoms and Experience (REALISE) survey. NPJ primary care respiratory medicine24(1), pp.1-10.

Quirt, J., Hildebrand, K. J., Mazza, J., Noya, F., and Kim, H. 2018. Asthma. Allergy, asthma, and clinical immunology : official journal of the Canadian Society of Allergy and Clinical Immunology14(Suppl 2), pp. 50.

Rhee, H., Wicks, M.N., Dolgoff, J.S., Love, T.M. and Harrington, D., 2018. Cognitive factors predict medication adherence and asthma control in urban adolescents with asthma. Patient preference and adherence12, p.929.

Rogliani, P., Calzetta, L., Ora, J., Cazzola, M. and Matera, M.G., 2019. Efficacy and safety profile of doxofylline compared to theophylline in asthma: a meta-analysis. Multidisciplinary respiratory medicine14(1), pp.1-8.

Silva, D. and Jacinto, T., 2016. Inhaled β2-agonists in asthma management: an evolving story. Breathe12(4), pp.375-377.

Zervas, E., Samitas, K., Papaioannou, A.I., Bakakos, P., Loukides, S. and Gaga, M., 2018. An algorithmic approach for the treatment of severe uncontrolled asthma. ERJ open research4(1).

Websites

Global Initiative for Asthma guidelines, 2021. REPORTS. Viewed on: 27/10/2021https://ginasthma.org/

Asthma UK, 2021. Quit smoking to lower your asthma risk. Viewed on: 28/10/2021<https://www.asthma.org.uk/advice/manage-your-asthma/quit-smoking/>

Lung Association, 2020. Asthma Self-Management Skills: Why Do I Need to Learn Them? Viewed on: 28/10/2021<https://www.lung.org/blog/asthma-self-management-skills>

World Health Organisation, 2021. Asthma. Viewed on: 28/10/2021<https://www.who.int/news-room/fact-sheets/detail/asthma>

Asthma UK, 2021. Asthma and stress. Viewed on: 28/10/2021<https://www.asthma.org.uk/advice/triggers/stress

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