Acute Exacerbation of Asthma Case File

Acute Exacerbation of Asthma Case File
https://medical-phd.blogspot.com/2021/05/acute-exacerbation-of-asthma-case-file.html
Eugene C. Toy, MD, Barry C. Simon, MD, Terrence H. Liu, MD, MHP, Katrin Y. Takenaka, MD, Adam J.
Rosh, MD, MS
Case 11
At 3 AM the paramedics call to inform you that they are en route to the emergency department with a 33-year-old
asthmatic. As she is brought in, you immediately notice that she is struggling to breathe. Sweat pours from her
face and body as her neck and chest heaves in an attempt to inhale another breath. Her efforts are ultimately
futile as consciousness slips away and she becomes apneic.
⯈ What are your initial priorities in the management of this patient?

⯈ What are your standard treatment options in managing her emergency medical condition?
ANSWER TO CASE 11:

Acute Exacerbation of Asthma
Summary: This is a case of a 33-year-old woman experiencing a severe asthma attack. Respiratory arrest is
imminent.
 Initial Priorities: The first priority in this patient’s management is addressing the ABCs (airway,
breathing, circulation). Based on this presentation, immediate protection of her airway with rapid-
sequence endotracheal intubation is indicated. Simultaneously, this patient should be placed on a cardiac
monitor with automated blood pressure measurement, establishment of IV access, and continuous pulse
oximetry.
 Standard treatment options: Basic treatment options include adrenergic agonists (eg, albuterol,
terbutaline), anticholinergic agents, and corticosteroids. Intravenous magnesium sulfate is often given to
patients with severe asthma exacerbations.
ANALYSIS
Objectives
1. Understand the pathophysiology of respiratory distress caused by acute asthma exacerbation.

2. Describe the key historical and physical examination features.
3. Be able to discuss treatment options for the patient with acute bronchospasm caused by asthma.
Considerations
This 33-year-old asthmatic patient has progressive respiratory difficulty until she becomes apneic. Regardless of
the underlying etiology, airway and breathing are the most important initial concerns in any patient. Attention to
the airway is critical, and in this case, rapid-sequence endotracheal intubation is the best option. Because airway
issues may arise at any given time, the emergency room physician must be skilled, rehearsed, and have
equipment to perform endotracheal intubation at any given time. Protection of the airway and mechanical
ventilation is the best therapy in this instance. Administration of beta-agonist agents, corticosteroids,
anticholinergic agents, and search for the trigger are likewise important.
Approach To:
Asthma
Epidemiology and Pathophysiology
In the United States, asthma accounts for more than 2 million emergency department (ED) visits, 456,000
hospitalizations, and 3500 deaths each year. Overall, between 4% and 8% of all adults carry a diagnosis of
asthma, with a higher prevalence reported in children, the elderly, and in Hispanic and African Americans. It is
the most common chronic disease in children and adolescents and the third leading cause of preventable
hospitalizations in the United States. Asthma results in more than 10 million lost school and workdays per year,
and results in $30 billion of medical expenses per year.
Asthma is considered a chronic inflammatory disorder of the airways. It consists of narrowing of the airway
leading to reduced airflow and can be induced by smooth muscle contraction, thickening of the airway wall, and
the presence of secretions within the airway lumen in response to an inciting allergen. In susceptible
individuals, these changes result in recurrent episodes of wheezing, breathlessness, chest tightness, and cough.
Two distinct phases of asthma have been described. The early (or immediate) phase of asthma consists of acute
airway hyperresponsiveness and reversible bronchoconstriction. Following allergen challenge, the lungs begin
to constrict within 10 minutes. Peak bronchoconstriction occurs at 30 minutes and either spontaneously or with
treatment resolves within 1 to 3 hours. With continued allergen challenge or with refractory
bronchoconstriction, this initial phase can progress into the late phase of asthma. This late (or delayed) phase of
asthma begins 3 to 4 hours after the allergen challenge and constitutes the inflammatory component seen with
acute asthma. Inflammatory cell recruitment, bronchial edema, mucoserous secretion, and further
bronchoconstriction all play key roles in the development and propagation of late-phase asthma. Whereas beta-2
agonists target the immediate phase of asthma, corticosteroids target the delayed phase.
Diagnosis
The typical asthma exacerbation is characterized by cough, chest tightness, dyspnea, and wheezing in a patient
with a known asthma history. Formal diagnosis is made by spirometry with 75% of asthmatics diagnosed before
age 7. Although wheezing characterizes airway obstruction and is often thought of as the hallmark finding in
asthma, it is not specific to asthma, and can be absent during severe asthma exacerbations. The history and
physical examination should focus on excluding other diagnoses while evaluating the severity of the current
asthma exacerbation. Key features to elicit are the nature and time course of the symptoms, precipitating
triggers (Table 11–1), use of medication prior to arrival, and any high-risk historical features (Table 11–2).
The evaluation of an asthmatic patient begins with the general appearance of the patient. Those who are
extremely anxious or drowsy, unable to speak in full sentences secondary to respiratory distress, or are using
accessory muscles of inspiration (tripod position/inability to lay supine) are at significant risk for rapid
decompensation. Additional worrisome features are signs of central cyanosis, hypoxia (pulse oximetry <90%),
significant tachypnea (>30 breaths per minute), tachycardia, diaphoresis, diffuse or absent wheezing, and poor
air entry on pulmonary examination.
Although extremely helpful, physical examination findings are not sensitive indicators of a clinically severe
exacerbation. Since asthmatics have a propensity for deteriorating quickly, an objective measure of severity
should be sought whenever possible. Bedside testing that measures peak expiratory flow rate (PEFR) or
fractional expiratory volume at 1 second (FEV1) are simple, inexpensive ways of measuring the severity of
airway obstruction and are commonly used to monitor response to treatment in the ED. Severe asthma is
defined as an FEV1 of less than 50% of predicted (typically <200 L/min in an adult) or one’s own personal best
measurement.
Routine laboratory investigations (eg, complete blood count, basic metabolic panel), arterial blood gas (ABG)
analysis, chest radiography, and cardiac monitoring are not required in the uncomplicated asthmatic. Table 11–3
suggests indications for each of these modalities.

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⯈ What are your initial priorities in the management of this patient?

ANSWER TO CASE 11:

1. Understand the pathophysiology of respiratory distress caused by acute asthma exacerbation.

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