Question

Initial History:

15 yo girl complaining of chest tightness and dyspnea

Mowing lawn when symptoms develop

Prodrome of rhinorrhea and tearing along with chest symptoms

Felt no better after going outside

Now one hour later

Additional information:

Hx of asthma since childhood, mother and brother have asthma

Allergic to grass, ragweed and cats

Productive cough clear phlegm

Uses a “blue” inhaler for past six months, BID

No other hx

Physical examination:

Alert, anxious, T=37, P=105, RR=30, BP=115/68, skin flushed and pink, diaphoretic, prolonged expository wheezes throughout all lung fields.

What therapies would immediately initiate?

Answer 1

This is a case of asthma exacerbation .

Therapies to be initiated immediately are :-

1. Oxygen.

Administration of oxygen through nasal cannulae or a mask is recommended to maintain SaO2 at greater than 90% (> 95% . Oxygen saturation should be monitored until a clear response to bronchodilator therapy has occurred.

2. Inhaled short-acting β2-agonists.

All patients should receive inhaled β2-agonist treatment because repetitive or continuous administration of these agents is the most effective means of reversing airflow obstruction .

In patients with severe exacerbations (i.e., < 40% of predicted value for either FEV1 or PEF), continuous administration of β2-agonists might be more effective than intermittent administration (17). The duration of bronchodilation from short-acting β2-agonists is not precisely known, but might be significantly shorter than in patients with stable asthma. Because of potential cardiotoxicity, only selective short-acting β-agonists (albuterol, levalbuterol, and pirbuterol) should be administered in high doses.

3. Systemic corticosteroids.

Systemic corticosteroids are recommended for most patients because they speed the resolution of airflow obstruction and reduce the rate of post-ED relapse .

4. Inhaled ipratropium bromide.

Multiple high doses (0.5 mg of nebulizer solution or 8 puffs by means of MDI in adults and 0.25–0.5 mg of nebulizer solution or 4–8 puffs by means of MDI in children) should be added to β2-agonist therapy to increase bronchodilation.