Status Asthmaticus Flashcards
A patient presents with asthma in acute distress. They have minimal benefit from repeated albuterol and ipratropium bromide treatments. What medication will you consider adding?
A. IV hydrocortisone
B. PO magnesium sulfate
C. Inhaled budesonide
D. IV amoxicillin
A. IV hydrocortisone
A patient presents with breathlessness and wheezing that has partially resolved after an albuterol treatment. Their FEV1/PEF ratio is 57%. What will you include in this patient’s plan of care?
A. Discharge home with pulmonary consult and continue home medications.
B. Admit for observation with PRN rescue medications.
C. Admit to progressive care with BiPAP and IV corticosteroids.
D. Admit to the ICU with mechanical ventilation and IV corticosteroids.
B. Admit for observation with PRN rescue medications.
Your patient is experiencing an episode of status asthmaticus with pulsus paradoxus. How is this phenomenon described?
A. A decrease in blood pressure with every expiration
B. An increase in blood pressure with every inspiration
C. A decrease in blood pressure with every inspiration
D. An increase in blood pressure with every expiration
C. A decrease in blood pressure with every inspiration
A patient in severe status asthmaticus shows signs of exhaustion and altered mental status. What complication is most imminent if not aggressively managed?
A. Respiratory arrest
B. Mild metabolic alkalosis
C. Bronchiectasis
D. Pulmonary edema
Correct Answer: A. Respiratory arrest
Rationale:
A patient with severe status asthmaticus who shows signs of exhaustion and altered mental status is at high risk for respiratory arrest. These clinical findings indicate that the patient is nearing respiratory failure, which is life-threatening if not managed aggressively. The other options (mild metabolic alkalosis, bronchiectasis, pulmonary edema) are either less acute or not typical immediate complications of severe asthma exacerbations.
- (Status Asthmaticus / Will Harm)
In status asthmaticus, which management error is most likely to harm the patient?
A. High-dose IV corticosteroids
B. Delayed escalation to continuous nebulized beta-agonists
C. IV magnesium sulfate for severe exacerbation
D. Concurrent ipratropium bromide therapy
Correct Answer: B. Delayed escalation to continuous nebulized beta-agonists
Rationale:
In status asthmaticus, timely escalation of therapy is crucial. Delaying the switch to continuous nebulized beta-agonists in a severe exacerbation can lead to worsening bronchospasm and potentially fatal respiratory failure. High-dose IV corticosteroids, IV magnesium sulfate, and concurrent ipratropium bromide are appropriate and beneficial interventions when used correctly in this context.
- (Status Asthmaticus / Common Intervention)
Which adjunct medication is commonly added for refractory bronchospasm after high-dose albuterol and ipratropium?
A. IV magnesium sulfate
B. Oral antibiotics
C. IV beta blockers
D. Oral decongestants
Correct Answer: A. IV magnesium sulfate
Rationale:
IV magnesium sulfate is commonly used as an adjunct therapy in refractory bronchospasm after high-dose albuterol and ipratropium have been administered. It helps to relax the smooth muscles in the airways and improve airflow. The other options (oral antibiotics, IV beta blockers, oral decongestants) are not appropriate for the management of bronchospasm in status asthmaticus.
A patient is conscious but is showing signs of worsening tension pneumothorax. What intervention needs to be immediately implemented?
A. Chest tube placement
B. Intubation
C. Needle decompression
D. Chest x-ray
A. Chest tube placement
- Which medication “will kill your patient” if misused in status asthmaticus?
A. Inhaled beta-agonists
B. Systemic corticosteroids (if not tapered properly, may cause adrenal crisis on abrupt withdrawal)
C. Anticholinergics
D. Leukotriene receptor antagonists
o Answer: B
o Rationale: Improper management of systemic steroids can lead to adrenal insufficiency, though acute misuse is rare; however, the real danger in status asthmaticus is the failure to relieve bronchospasm
- Status asthmaticus is best defined as:
A. Mild asthma controlled with inhalers
B. Severe, life-threatening asthma exacerbation unresponsive to standard treatments
C. Chronic stable asthma
D. Exercise-induced asthma
o Answer: B
o Rationale: Status asthmaticus is a severe, refractory asthma exacerbation that can be fatal if not treated aggressively
- What is “really common” in the initial management of status asthmaticus?
A. Immediate intubation in all cases
B. High-dose inhaled beta-agonists with supplemental oxygen
C. Exclusive use of anticholinergics
D. Observation only
o Answer: B
o Rationale: High-dose inhaled beta-agonists and oxygen are the cornerstones of initial therapy
- Which complication “will harm your patient” if status asthmaticus is not treated promptly?
A. Development of pneumonia
B. Respiratory failure requiring mechanical ventilation
C. Weight loss
D. Hypertension
o Answer: B
o Rationale: Untreated status asthmaticus can progress to respiratory failure and require intubation, significantly increasing mortality risk.
A 32-year-old woman with known asthma presents with severe shortness of breath, inability to speak in full sentences, and accessory muscle use after a massive exposure to allergens. Her peak expiratory flow rate (PEFR) is 50 L/min (well below her personal best). What is the most immediate management step?
A) Administer high-flow oxygen, nebulized albuterol, and ipratropium
B) Order a chest X-ray before initiating therapy
C) Start oral corticosteroids and schedule outpatient follow-up
D) Initiate heliox therapy as the primary treatment
Answer: A
Rationale: In status asthmaticus, rapid intervention with supplemental oxygen and aggressive bronchodilation is critical to prevent respiratory failure
A 45-year-old man in status asthmaticus is brought to the ED. His PEFR is 35% of his predicted value, and he has minimal improvement 30 minutes after his last nebulized treatment. What is the best disposition for this patient?
A) Discharge home with increased inhaler use
B) Admit to the general ward for observation
C) Admit to the ICU for close monitoring and aggressive therapy
D) Send for outpatient pulmonary function testing
Answer: C
Rationale: Lack of significant improvement (<10% increase) and a very low PEFR (<40% predicted) indicate the need for ICU-level care.
A 28-year-old woman with known asthma presents with acute wheezing and shortness of breath. Her initial arterial blood gas (ABG) shows respiratory alkalosis with hypoxemia. As she worsens, repeat ABG reveals rising CO₂ levels and respiratory acidosis. What does this change most indicate?
A) Improvement in her ventilation
B) The onset of respiratory muscle fatigue and impending ventilatory failure
C) A laboratory error requiring repeat testing
D) That she is responding to nebulized therapy
Answer: B
Rationale: A shift from respiratory alkalosis to acidosis in status asthmaticus signals CO₂ retention and impending respiratory failure
A 50-year-old woman with status asthmaticus shows only a 5% improvement in her peak expiratory flow rate 30 minutes after bronchodilator therapy. Which additional treatment should be considered promptly?
A) Observation and reassurance
B) Administration of intravenous corticosteroids
C) Scheduling a repeat pulmonary function test in 2 hours
D) Discharging her with an increased dose of inhaled beta-agonists
Answer: B
Rationale: Inadequate improvement mandates escalation of therapy with IV corticosteroids to reduce inflammation and potentiate bronchodilator effects.
A 40-year-old man with a history of poorly controlled asthma presents with status asthmaticus. Which of the following best explains the pathophysiologic mechanism behind his air trapping and ventilation-perfusion mismatch?
A) Airway hyperresponsiveness leading to premature airway closure during exhalation
B) Excessive mucociliary clearance causing rapid exhalation
C) Overactivity of sympathetic pathways causing bronchodilation
D) Decreased functional residual capacity due to alveolar collapse
Answer: A
Rationale: Premature airway closure results in air trapping, increased functional residual capacity, and subsequent V/Q mismatch, leading to hypoxemia.
A 35-year-old woman with status asthmaticus has been started on high-dose nebulized albuterol and ipratropium. What adjunctive therapy can be used to promote smooth muscle relaxation if she remains refractory to initial therapy?
A) Oral leukotriene inhibitors
B) Intravenous magnesium sulfate
C) Subcutaneous epinephrine
D) Inhaled corticosteroids only
Answer: B
Rationale: IV magnesium sulfate is an effective adjunct to relax bronchial smooth muscle in severe, refractory cases.
In a patient with status asthmaticus, heliox (a mixture of helium and oxygen) is sometimes used. What is the primary rationale for using heliox in these patients?
A) It acts as a potent bronchodilator
B) It decreases airway resistance and turbulent flow, reducing work of breathing
C) It directly reduces mucosal edema
D) It enhances the absorption of corticosteroids
Answer: B
Rationale: Heliox’s lower density improves laminar flow through narrowed airways, decreasing work of breathing.
A 42-year-old man in status asthmaticus is showing slight improvement in his peak flow measurements (improved by 35% of his personal best) 30 minutes after treatment. How should his disposition be determined?
A) He can be discharged home immediately
B) He should be admitted for observation
C) He requires ICU admission for further management
D) He should be transferred for immediate mechanical ventilation
Answer: B
Rationale: An improvement of 30% (but still not >70% of predicted) indicates a partial response, warranting observation (often in an observation unit or hospital ward).
A 30-year-old man presents with status asthmaticus. His history reveals poor adherence to his inhaler regimen and significant psychosocial stress. What additional step is critical before discharge?
A) Repeat chest X-ray
B) Psychosocial evaluation and arrangement of community support services
C) Scheduling a follow-up pulmonary function test
D) Initiating long-term oxygen therapy
Answer: B
Rationale: Social determinants can contribute to poor asthma control; addressing these is essential to prevent recurrent exacerbations.
A 38-year-old woman in status asthmaticus develops sudden unilateral chest pain and subcutaneous emphysema during her hospital stay. What complication should you suspect, and what is the next step?
A) Pulmonary embolism; obtain a CT angiogram
B) Pneumothorax; perform an immediate chest X-ray
C) Myocardial infarction; obtain an EKG
D) Aspiration pneumonia; order a sputum culture
Answer: B
Rationale: Sudden chest pain with subcutaneous emphysema in this setting is highly suggestive of a pneumothorax; prompt imaging is required.
Which bedside tool is most useful for objectively assessing the severity of airflow obstruction in a patient with status asthmaticus?
A) Pulse oximetry
B) Arterial blood gas (ABG) analysis
C) Peak expiratory flow rate (PEFR) measurement
D) Chest auscultation alone
Answer: C
Rationale: PEFR is a quick, quantitative method to assess airway obstruction and response to treatment.
A 29-year-old woman with severe asthma is admitted with status asthmaticus. Despite maximal medical therapy, she develops hypercapnia. What is the next step in ventilatory management?
A) Begin noninvasive positive pressure ventilation (NIPPV)
B) Increase the dose of nebulized beta-agonists
C) Intubate and initiate mechanical ventilation
D) Administer additional magnesium sulfate
Answer: C
Rationale: Hypercapnia signifies ventilatory failure; if noninvasive measures fail or the patient worsens, intubation and mechanical ventilation are indicated.
A 50-year-old man with status asthmaticus is intubated. Which ventilation strategy is recommended to avoid barotrauma in these patients?
A) High tidal volume ventilation
B) Permissive hypercapnia with low tidal volume ventilation
C) Aggressive ventilation to normalize PaCO₂ immediately
D) Routine use of PEEP greater than 10 cm H₂O
Answer: B
Rationale: Permissive hypercapnia with low tidal volumes minimizes high intrathoracic pressures and barotrauma, which is beneficial in severe asthma.
A patient with status asthmaticus is receiving nebulized albuterol every 20 minutes. What is the primary benefit of adding systemic corticosteroids early in the treatment?
A) They provide immediate bronchodilation
B) They reduce airway inflammation and mucus production, enhancing beta-agonist responsiveness
C) They directly reverse mucus plugging
D) They eliminate the need for supplemental oxygen
Answer: B
Rationale: Systemic corticosteroids decrease airway inflammation and potentiate beta-agonist effects, though their onset is not immediate.
A 35-year-old woman with status asthmaticus demonstrates a marked drop in systolic blood pressure (by >10 mmHg) during inspiration (pulsus paradoxus). What does this finding most likely indicate?
A) Effective response to beta-agonists
B) Severe airway obstruction and increased intrathoracic pressure
C) Cardiac tamponade
D) An incidental finding with no clinical significance
Answer: B
Rationale: Pulsus paradoxus is a common sign in severe asthma due to increased intrathoracic pressure from airway obstruction.
Which of the following findings on an arterial blood gas (ABG) would prompt an urgent need for further escalation of care in status asthmaticus?
A) pH 7.48 with low PaCO₂
B) pH 7.36 with normal PaCO₂
C) pH 7.30 with rising PaCO₂ and hypoxemia
D) pH 7.50 with high PaO₂
Answer: C
Rationale: A pH indicating acidosis with rising PaCO₂ suggests respiratory fatigue and impending failure.
A 40-year-old man with status asthmaticus is not improving with high-dose nebulized beta-agonists. Which medication is considered a second-line bronchodilator in this setting?
A) Ipratropium bromide
B) Terbutaline
C) Salmeterol
D) Montelukast
Answer: A
Rationale: Ipratropium bromide (an anticholinergic) is commonly added to beta-agonists for additional bronchodilation.
In mechanically ventilated patients with status asthmaticus, what ventilator strategy may help reduce dynamic hyperinflation?
A) High respiratory rates with short expiratory times
B) Prolonged expiratory time (lower respiratory rate) and low tidal volumes
C) Immediate normalization of CO₂ levels
D) High PEEP levels to maintain alveolar recruitment
Answer: B
Rationale: Allowing a longer expiratory phase with low tidal volumes minimizes air trapping and dynamic hyperinflation.
A 28-year-old woman in status asthmaticus develops arrhythmias during her ICU stay. Which of the following complications is most likely contributing to her arrhythmia?
A) Hypokalemia due to beta-agonist use
B) Hyperkalemia from corticosteroids
C) Direct toxic effect of magnesium sulfate
D) Overuse of ipratropium
Answer: A
Rationale: Beta-agonists can drive potassium into cells, causing hypokalemia, which may lead to arrhythmias.
Before discharging a patient after an episode of status asthmaticus, which nonpharmacologic factor is critical to address?
A) Scheduling a routine chest CT scan
B) Evaluating and addressing the home environment and trigger exposures
C) Arranging for long-term oxygen therapy
D) Instructing on increased exercise regimens
Answer: B
Rationale: Addressing environmental triggers and social factors is essential to prevent recurrent exacerbations.
A patient with status asthmaticus undergoes a chest X-ray primarily to:
A) Confirm the diagnosis of asthma
B) Rule out complications such as pneumothorax or pneumonia
C) Evaluate the degree of airway narrowing
D) Monitor response to nebulizer therapy
Answer: B
Rationale: The chest X-ray is used to rule out other etiologies or complications, such as pneumothorax, that may mimic or complicate status asthmaticus.
Status asthmaticus is characterized by two distinct phases. What best differentiates the early bronchospastic phase from the later inflammatory phase?
A) Early phase involves mucus plugging, while later phase is solely due to bronchospasm
B) Early phase is mediated by mast cell degranulation; later phase involves airway edema and eosinophilic inflammation
C) Early phase shows airway remodeling; later phase shows immediate bronchodilation
D) Early phase is unresponsive to beta-agonists; later phase responds well
Answer: B
Rationale: The early phase is due to mast cell degranulation and immediate bronchoconstriction, whereas the later phase is marked by inflammatory edema and mucus gland hyperactivity.
In status asthmaticus, which arterial blood gas pattern is most typical in the early stages?
A) Metabolic acidosis with hypercapnia
B) Respiratory alkalosis with hypoxemia
C) Normal pH with high CO₂
D) Metabolic alkalosis with normocapnia
Answer: B
Rationale: Early in an asthma exacerbation, patients hyperventilate, leading to respiratory alkalosis despite hypoxemia.
For a patient requiring intubation in status asthmaticus, which additional measure may be needed to facilitate ventilatory management?
A) Immediate extubation
B) Deep sedation with neuromuscular blockade
C) High-frequency oscillatory ventilation
D) Use of high tidal volumes to force air out
Answer: B
Rationale: Sedation with neuromuscular blockade can help control the work of breathing and reduce dynamic hyperinflation in intubated patients.
Which pathophysiologic process in status asthmaticus is most responsible for the development of hypoxemia?
A) Increased mucociliary clearance
B) Ventilation-perfusion mismatch due to air trapping
C) Excessive oxygen uptake
D) Systemic vasodilation
Answer: B
Rationale: Air trapping and premature airway closure lead to ventilation-perfusion mismatch, resulting in hypoxemia.
A 28-year-old woman with a history of severe asthma presents to the ED with severe dyspnea, wheezing, and an inability to speak full sentences. She is using accessory muscles, and her respiratory rate is 35 breaths/min. What is the most immediate management step?
A) Obtain an arterial blood gas
B) Administer nebulized albuterol and ipratropium, start oxygen therapy
C) Intubate immediately
D) Order a chest X-ray
Answer: B
Rationale: The first step in managing status asthmaticus is aggressive bronchodilator therapy (albuterol/ipratropium) and oxygen to relieve bronchospasm and correct hypoxia.
A 33-year-old man presents with severe shortness of breath and wheezing. His history and exam suggest status asthmaticus, but you must also consider other diagnoses. Which of the following is NOT on your differential?
A) Pneumothorax
B) Airway obstruction (e.g., foreign body)
C) Acute coronary syndrome
D) Pneumomediastinum
Answer: C
Rationale: While pneumothorax, airway obstruction, and pneumomediastinum are important differentials in severe asthma, acute coronary syndrome is less likely in a young patient with an asthma exacerbation unless additional risk factors exist.
Which of the following is an indication for initiating noninvasive positive pressure ventilation (NIPPV) in status asthmaticus?
A) Mild wheezing with normal ABG
B) Early hypercapnia with moderate respiratory distress in a cooperative patient
C) Complete response to nebulized beta-agonists
D) Normal peak expiratory flow rate
Answer: B
Rationale: In selected patients with moderate hypercapnia and respiratory distress, NIPPV may help avoid intubation when the patient is cooperative and not in extremis.
A 40-year-old man with severe asthma presents in acute respiratory distress. He is diaphoretic, unable to speak, and his breath sounds are absent on auscultation. What is the most likely explanation for the absent breath sounds?
A) Resolution of the asthma attack
B) Pneumothorax
C) Worsening bronchoconstriction leading to a silent chest
D) Aspiration pneumonia
Answer: C
Rationale: A silent chest (no wheezing or breath sounds) in a patient with status asthmaticus indicates severe airway obstruction and impending respiratory failure.
A patient in status asthmaticus develops severe lactic acidosis on repeat ABG. This most likely indicates:
A) Effective bronchodilation
B) Tissue hypoxia due to impaired ventilation
C) Overcorrection with high-flow oxygen
D) Metabolic compensation for respiratory alkalosis
Answer: B
Rationale: Lactic acidosis reflects anaerobic metabolism secondary to hypoxemia and inadequate ventilation.
In monitoring a patient with status asthmaticus, a >30% improvement in peak expiratory flow rate (PEFR) from baseline is considered:
A) An indication for immediate ICU discharge
B) A marker of significant clinical improvement
C) Insufficient change to alter management
D) A sign of impending respiratory failure
Answer: B
Rationale: A 30% improvement in PEFR is generally considered a favorable response, though continued monitoring is necessary.
Social factors play a significant role in the recurrence of status asthmaticus. Which of the following is most important to assess before discharging a patient?
A) Their ability to use a peak flow meter
B) Their home environment and exposure to triggers
C) Their baseline cholesterol levels
D) Their employment status
Answer: B
Rationale: A thorough evaluation of the home environment and potential triggers is essential to reduce the risk of recurrent severe asthma exacerbations.
A 34-year-old man with a history of severe asthma is started on nebulized albuterol every 20 minutes. He begins to develop tachycardia and muscle tremors. What is the most likely cause?
A) Worsening asthma
B) Beta-agonist toxicity
C) Hypoxia-related cardiac arrhythmia
D) Pulmonary embolism
Answer: B
Rationale: Frequent albuterol use can lead to beta-agonist toxicity, which presents with tachycardia, tremors, and hypokalemia.
Which of the following is a second-line agent for status asthmaticus in a patient not responding to beta-agonists?
A) Montelukast
B) Magnesium sulfate
C) Cromolyn sodium
D) Oral theophylline
Answer: B
Rationale: IV magnesium sulfate acts as a smooth muscle relaxant and is used for refractory bronchospasm.
Which of the following arterial blood gas (ABG) findings suggests impending respiratory failure in a patient with status asthmaticus?
A) pH 7.50, PaCO₂ 25 mmHg
B) pH 7.45, PaCO₂ 40 mmHg
C) pH 7.32, PaCO₂ 55 mmHg
D) pH 7.36, PaCO₂ 35 mmHg
Answer: C
Rationale: Rising PaCO₂ (hypercapnia) and a pH trending toward respiratory acidosis indicate respiratory muscle fatigue and impending ventilatory failure.
Which of the following is an absolute indication for intubation in a patient with status asthmaticus?
A) Persistent wheezing despite albuterol therapy
B) PaCO₂ >50 mmHg with respiratory acidosis
C) Peak expiratory flow rate (PEFR) improving to >50% of predicted
D) Respiratory rate of 25 breaths/min
Answer: B
Rationale: Hypercapnia (PaCO₂ >50 mmHg) with respiratory acidosis signals respiratory failure, requiring mechanical ventilation.
Which ventilatory strategy is most appropriate for an intubated patient with status asthmaticus?
A) High tidal volume and high respiratory rate
B) Low tidal volume, prolonged expiratory time, and permissive hypercapnia
C) Continuous positive airway pressure (CPAP) only
D) Immediate correction of CO₂ levels with hyperventilation
Answer: B
Rationale: Permissive hypercapnia and prolonged expiratory time help prevent air trapping and dynamic hyperinflation.
A 25-year-old woman with status asthmaticus has been on continuous nebulized albuterol. Her potassium level is 2.8 mEq/L. What is the best course of action?
A) Continue albuterol without changes
B) Discontinue beta-agonists
C) Administer IV potassium replacement
D) Start IV fluids with sodium bicarbonate
Answer: C
Rationale: Beta-agonists cause intracellular potassium shifts, leading to hypokalemia, which should be corrected.
Which of the following findings in a patient with status asthmaticus is a poor prognostic indicator?
A) Wheezing on auscultation
B) Pulsus paradoxus >15 mmHg
C) Peak expiratory flow rate (PEFR) improving by 50%
D) Improvement after first nebulizer treatment
Answer: B
Rationale: Pulsus paradoxus >15 mmHg suggests severe airway obstruction and increased intrathoracic pressure.
Which of the following factors is most associated with fatal outcomes in status asthmaticus?
A) Male gender
B) Underuse of inhaled corticosteroids
C) Frequent upper respiratory infections
D) Increased eosinophil count
Answer: B
Rationale: Poor adherence to inhaled corticosteroids increases the risk of severe asthma attacks and fatal exacerbations.
What is the most appropriate first-line therapy for a patient with status asthmaticus and an SpO₂ of 85%?
A) High-flow oxygen and nebulized albuterol
B) BiPAP ventilation
C) Heliox therapy
D) Oral prednisone
Answer: A
Rationale: Oxygen therapy and bronchodilators are the first-line treatments.
What is the role of corticosteroids in the management of status asthmaticus?
A) Immediate bronchodilation
B) Reduction of airway inflammation and mucus production
C) Replacement therapy for adrenal insufficiency
D) Treatment of concurrent infection
Answer: B
Rationale: Corticosteroids reduce airway inflammation and mucus production, but their effects take several hours.
A 40-year-old man with status asthmaticus suddenly develops chest pain and hypotension. Breath sounds are diminished on one side. What is the most likely diagnosis?
A) Myocardial infarction
B) Pneumothorax
C) Pulmonary embolism
D) Atelectasis
Answer: B
Rationale: Patients with severe asthma are at risk for pneumothorax due to high intrathoracic pressures.
A 33-year-old woman with status asthmaticus improves after 4 hours of treatment. What is the most important factor before discharging her home?
A) Prescription for nebulized albuterol
B) Social determinants of health assessment
C) Routine spirometry testing
D) Checking eosinophil levels
Answer: B
Rationale: Social determinants (e.g., access to medications, triggers at home) significantly impact asthma control.
What is the most common complication of mechanical ventilation in status asthmaticus?
A) Pulmonary embolism
B) Dynamic hyperinflation and barotrauma
C) Acute kidney injury
D) Diaphragmatic paralysis
Answer: B
Rationale: Ventilator-induced hyperinflation increases intrathoracic pressure, predisposing to barotrauma (e.g., pneumothorax).
A 27-year-old woman with a history of severe asthma presents in status asthmaticus. She is diaphoretic, using accessory muscles, and has absent breath sounds. Her PaCO₂ has risen from 38 mmHg to 58 mmHg in the last hour. What is the next best step?
A) Continue frequent nebulized albuterol and reassess in 30 minutes
B) Administer IV magnesium sulfate and continue bronchodilators
C) Prepare for intubation and mechanical ventilation
D) Order a chest CT to evaluate for pulmonary embolism
Answer: C
Rationale: A rising PaCO₂ with respiratory acidosis indicates impending respiratory failure, requiring intubation. A silent chest is a dangerous sign of severe airflow obstruction.
A 50-year-old man with severe asthma is admitted to the ICU for status asthmaticus. He has been on continuous nebulized beta-agonists for several hours. Labs reveal potassium 2.7 mEq/L. What is the most appropriate next step?
A) Continue current treatment and monitor
B) Administer IV potassium replacement
C) Discontinue albuterol and switch to ipratropium only
D) Add oral corticosteroids and monitor
Answer: B
Rationale: Beta-agonists (albuterol) drive potassium intracellularly, leading to hypokalemia, which can cause cardiac arrhythmias. Potassium replacement is necessary.
A 32-year-old man presents with severe status asthmaticus. He is placed on mechanical ventilation. What ventilator setting is most appropriate to prevent barotrauma?
A) High tidal volume, high respiratory rate
B) Low tidal volume, prolonged expiratory time, and permissive hypercapnia
C) Immediate normalization of PaCO₂
D) High positive end-expiratory pressure (PEEP)
Answer: B
Rationale: Permissive hypercapnia and prolonged expiratory time prevent air trapping and barotrauma. High tidal volumes worsen dynamic hyperinflation.
A 25-year-old woman presents in status asthmaticus with SpO₂ 88% on room air. She is given continuous nebulized albuterol and IV corticosteroids but remains in severe distress. What adjunctive therapy may help improve airflow?
A) IV theophylline
B) IV magnesium sulfate
C) Inhaled corticosteroids
D) Leukotriene receptor antagonists
Answer: B
Rationale: IV magnesium sulfate is a bronchodilator that relaxes smooth muscle and is used in severe, refractory asthma exacerbations.
A 60-year-old woman with asthma presents with acute respiratory distress. She is tachycardic, has pulsus paradoxus of 20 mmHg, and is struggling to breathe despite aggressive therapy. What is the best immediate next step?
A) Give IV fluids and continue nebulized beta-agonists
B) Start noninvasive positive pressure ventilation (NIPPV)
C) Perform bedside thoracic ultrasound to rule out pneumothorax
D) Prepare for intubation
Answer: D
Rationale: Severe respiratory distress with pulsus paradoxus and failure to improve despite aggressive therapy indicates impending respiratory failure, requiring intubation.
Which of the following findings differentiates status asthmaticus from simple asthma exacerbation?
A) FEV₁ improving to >70% of baseline after beta-agonists
B) Normal PaCO₂ on arterial blood gas
C) Respiratory alkalosis and mild hypoxemia
D) Hypercapnia and a silent chest
Answer: D
Rationale: Hypercapnia and a silent chest indicate severe obstruction and respiratory failure, distinguishing status asthmaticus from a milder asthma exacerbation.
A 45-year-old man with status asthmaticus is being considered for discharge. Which factor is most important before discharging him?
A) He is no longer wheezing
B) His peak expiratory flow rate (PEFR) is >70% of predicted
C) His chest X-ray is normal
D) He has been afebrile for 24 hours
Answer: B
Rationale: PEFR >70% of predicted indicates sufficient improvement to safely discharge the patient. Wheezing may persist but is not a reliable indicator of severity.
Which of the following is a late and concerning finding in a patient with status asthmaticus?
A) Pulsus paradoxus
B) Hypoxia
C) Absence of wheezing with silent chest
D) Tachypnea
Answer: C
Rationale: A silent chest is an ominous sign indicating severe airway obstruction and possible impending respiratory failure.
A 55-year-old woman with a history of severe asthma presents in status asthmaticus. She has been intubated and is on mechanical ventilation. Her peak inspiratory pressures are high, and she is hypotensive. What is the most likely cause?
A) Dynamic hyperinflation leading to auto-PEEP
B) Sepsis-induced hypotension
C) Right heart failure
D) Pulmonary embolism
Answer: A
Rationale: Auto-PEEP (intrinsic PEEP) due to air trapping increases intrathoracic pressure, reducing venous return and causing hypotension.
Impending respiratory failure
→ Hypercapnia (PaCO₂ >50 mmHg), silent chest, altered mental status → Intubate
A 23-year-old woman with status asthmaticus is started on IV corticosteroids. When should she be transitioned to oral corticosteroids?
A) Immediately after her first IV dose
B) Once her peak expiratory flow rate (PEFR) is >50% of baseline
C) 24–48 hours after IV therapy, once stabilized
D) Once her SpO₂ is consistently >95%
Answer: C
Rationale: IV corticosteroids should be continued for 24–48 hours before transitioning to oral prednisone to prevent rebound inflammation
Refractory cases →
Consider IV magnesium sulfate, noninvasive ventilation (if appropriate)
Ventilator Complications to watch for →
Auto-PEEP, barotrauma (pneumothorax), beta-agonist-induced hypokalemia
Ventilator management
Low tidal volumes, prolonged expiratory time, permissive hypercapnia
→ PEFR >70%, corticosteroid tapering, home environment assessment
Asthma patient Discharge criteria
