CCS Interactive Case 19

Question 1

36 y/o M, history of asthma, presents to ED w/shortness of breath, wheezing, cough. Last exacerbation 1 year ago, never been hospitalized for asthma. Smoker. Tachypneic, tachycardic.

DDx?

Answer 1

Acute asthma exacerbation

Pneumothorax, pulmonary embolism, cardiogenic pulmonary edema, pneumonia, upper airway obstruction (anaphylaxis)

Question 2

First step?

Answer 2

Pulse ox, oxygen therapy, IV access, head elevation.

Question 3

Pulse ox reveals O2 saturation of 90% on RA.

Exam steps?

Answer 3

General, HEENT, chest/lung, heart, abdomen, extremities

Question 4

Moderate respiratory distress, accessory muscle use, inspiratory and expiratory wheezes, hyperresonance, equal air entry bilaterally, tachycardia

Next step?

Answer 4

Confirm diagnosis of asthma exacerbation and assess severity

Peak expiratory flow rate (PEFR)
PEFR <200 L/min or <40% of personal best = severe

ABG
CXR

Question 5

PEFR of 240 (lower than normal)
PO2 60 (lower than normal)
PCO2 33 (lower than normal)
pH 7.48 (higher than normal)
Hyperinflation on CXR`

Rx?

Answer 5

Consistent with mild-moderate exacerbation

Pharmacologic therapy

Question 6

Lack of improvement within first 4 hours?

Answer 6

Admit

Question 7

Management of asthma exacerbation - if impending respiratoryarrest is suspected?

Answer 7

Intubate, mechanically ventilate, admit to ICU
Give nebulized albuterol/ipratropium
Give systemic steroids

Question 8

Management of asthma exacerbation - no suspicion of impending respiratory arrest + PEFR<40% predicted

Answer 8

O2 therapy with goal 90+%
Give albuterol/ipratropium by nebulizer Q20 min
IV steroids
Reassess PEFR every hour
Admit within 4 hours

Question 9

Management of asthma exacerbation - no suspicion of impending respiratory arrest + PEFR>40% predicted

Answer 9

O2 therapy w/goal 90+%
Give albuterol/ipratropium by nebulizer
Oral steroids
If PEFR does not improve to >70% predicted, add ipratropium
Admit within 4 hours

Question 10

Decision to admit?

Answer 10

Admit for PEFR <40%predicted at 4 hours
Consider for PEFR 40-70% at 4 hours
D/C home for PEFR>70% at 4 hours

Question 11

Sequence?

Answer 11

Order: pulse oximetry Q1hr, oxygen, IV access, head elevation, cardiac monitor
Exam: focused (general, HEENT/neck, chest/lung, CV, abd, ext/spine)
order: ABG, peak flow (PEFR), EKG, portable CXR, CBC, BMP (all stat)
Albuterol nebulizer, continuous
Prednisoone (PO) continuous or IV methyl pred

Reevaluate in 40-60 minutes
Interval f/u + general/lung exam - patient still in respiratory distress

Ipratropium bromide, nebulizer, continuous

Reevaluate every hour for 3 hours. Request interval f/u and general/lung exam. Still in respiratory distres, non-responder and needs to be admitted

Transfer to ward

Peak flow Q2hours, NPO, IV NSS 0.9%, complete bedrest

Re-evaluate every 2-4hours
Patient improves
Case ends
Order: counseling
Cancel NPO, bed rest, cardiac monitor
Order: normal diet, ambulate at will
Primary dx: acute exacerbation of bronchial asthma