Clinical Pathway For Management Of Acute Asthma

Acutely Life-Threatening Diagnoses That May Mimic Asthma

Acute Asthma In The Pediatric Emergency Department Case Study

Case Study:
An 8-year-old boy is brought into your emergency department in the middle of the night with dyspnea. His mother states he has wheezed in the past, but he has been doing well since starting inhaled fluticasone. He only requires a few puffs of an albuterol metered-dose inhaler 2 or 3 times per week for relief. He has recently experienced coughing and a runny nose. The patient’s mother also admits that their family just started using a woodburning stove. Tonight the patient developed increasing shortness of breath which could not be relieved by several puffs of albuterol. Otherwise, he is healthy. On examination, you notice that he is working hard to breathe with supraclavicular, intercostal, and subcostal retractions. On auscultation, his lungs have poor aeration without wheezing. He is breathing 48 times per minute, his heart rate is 140, and his O2 saturation is 90%. How aggressive should you be with his treatment? What therapies would best treat his shortness of breath? What diagnostic studies does he require?

Case Study Conclusion:
You rapidly identify this patient as having a severe asthma exacerbation and needing aggressive management. You start continuous albuterol and ipratropium and administer a dose of corticosteroid. The patient continues to have severe distress and appears anxious. You give subcutaneous epinephrine, place an IV, and administer magnesium and a normal saline bolus. You also ask his respiratory therapist to administer his aerosol medications via BiPAP, which results in improvement in his retractions and anxiety. Within 15 minutes, wheezing is audible in his lung fields. You reassess him frequently, and his respiratory rate decreases over the next hour, after which you transition him to aerosols via a simple mask, which he tolerates well. After 2 hours, he is able to speak in full sentences and perform a peak flow, which is 50% of expected. You are able to transition him from continuous albuterol aerosols to intermittent treatments every 2 hours, but his oxygen saturations remain 92% while on room air. You contact his primary care physician and admit him to the hospital for continued treatment of his acute asthma exacerbation. He remains in the hospital for 2 days, after which he is discharged on an increased dose of fluticasone as a daily controller medication.

Staging Of COPD Based On Post-Bronchodilator Spirometric Criteria

Chronic Obstructive Pulmonary Disease Risk Management Pitfalls

3. “I didn’t give inhaled bronchodilators because he was so tachycardic.” Although tachycardia may be a side effect of inhaled bronchodilators, it is rarely if ever hemodynamically significant, and hemodynamic compromise is of secondary concern if respiratory failure is untreated (“B comes before C”).

4. “I thought the rule about giving too much oxygen is just for internists on the ward.” For reasons that remain contentious and poorly understood, some patients will develop worsened hypercapnic respiratory failure in the face of hyperoxia. We currently have no way of identifying which patients will develop this response. In the absence of a compelling argument in favor of hyperoxia, the prudent approach is to give no more oxygen than is necessary to achieve an SaO2 in the range of 88%–92%.

5. “His ABG didn’t indicate that he required intubation,” or the closely related “His pulse-ox was just fine until…” Numeric values may be deceptive, especially in the COPD patient, who may have striking and unpredictable abnormalities at baseline and even more so when acutely decompensated. Therefore, it is of paramount importance that decisions regarding airway management and aggressive management be based on integration of the overall clinical picture rather than one or two laboratory or monitoring values.

6. “I adjusted the ventilator to weight-appropriate settings.” Permissive hypercapnia is an effective strategy to maintain oxygenation while avoiding iatrogenic VILI. While it can be very uncomfortable to leave a patient at a pH of 7.20, carbon dioxide narcosis is no longer of concern once a patient is intubated, and the mild acidemia does not appear to be of clinical consequence.

Chronic Obstructive Pulmonary Disease Case Study

Case Study:
A 57-year-old male is brought in by paramedics from home after he called 911 saying, “I can’t breathe.” He is thin, has weathered skin, and is visibly dyspneic. His pulse oximetry reading is 84% despite receiving home oxygen via nasal cannula. When you listen to his lungs, you hear almost nothing. Fifteen minutes ago, you sent a patient with septic shock to your hospital’s last ICU bed. What strategies can you employ to rapidly turn this patient around and prevent him from getting intubated?

A 78-year-old female with a history of “heart problems” and “chronic bronchitis” is brought in by family members who report that she has been increasingly fatigued over the past day and complaining of “not breathing right.” She reports that her inhalers are not helping her like they should. She has mild hypoxia, scattered wheezes, lower extremity edema, and cardiomegaly on chest x-ray. How can the relative roles of cardiac and pulmonary disease be elucidated in her current presentation? How useful would a BNP value be in your management? Should you consider pulmonary embolism highly in your differential diagnosis?

Case Study Conclusion:
While simultaneously starting nebulized bronchodilators and steroids for the 57-year-old male, you call for chest x-ray and BiPAP. Although it takes a few minutes for respiratory therapy to set things up, the patient responds well to therapy and begins to turn around. An hour after arrival, he is tolerating BiPAP well and appears much more comfortable. His venous blood gas shows only mild acidosis and hyponatremia. His chest x-ray is unremarkable, but he describes a marked change in the quality of his sputum over the past several days, so you start antibiotics. After several hours of observation, you feel comfortable admitting him to the medicine ward.

Given her age, comorbidities, and the unclear clinical circumstances, you treat the 78-year-old female aggressively for both decompensated COPD and heart failure. You forgo the BNP, since it would be unlikely to change your clinical management. You give her aspirin, nitrates, bronchodilators, steroids, and antibiotics. She has been largely sedentary and has normal renal function, so you order a CT angiogram of her chest. Meanwhile, she reports that the bronchodilators and nitrates have made her breathing feel better. After confirming that the CT shows no pulmonary emboli, you admit the patient to a telemetry-monitored bed where she can continue to have serial troponins drawn.

Glascow Coma Scale Modified For Pediatric Patients

Accidental Trauma Of Infancy Key Points

Key Points:
1. Evaluation of pediatric trauma should follow the ABCDEF algorithm similar to adults with the unique physiologic response of the infant to trauma taken into consideration (eg, normal blood pressure maintained in a shock state, greater risk for hypothermia).

2. Family presence during infant resuscitation is recommended and may help families better cope with the emotional turmoil of their family member being injured.

3. Diagnostic studies are not always necessary for the infant victim of accidental injury, and the utility of specific laboratory and imaging studies is highly case-specific.

4. Safe disposition of an injured infant is a clinical judgment. Discharge from the emergency department can be appropriate in special circumstances of minor trauma with appropriate supervision and follow-up. Suspicion of any non-accidental trauma or abuse should be reported as mandated by law. Child protective services should be involved to aid in the safe placement of children suspected of abuse. Admission should be made when medically indicated.

Accidental Trauma Of Infancy Case Study

Case Study:
You pause outside the closed door to glance at your patient’s chart. This patient has no past medical history and is complaining of the effects of a fall. As you skim the paperwork in your hands, you are distracted by loud sobs from inside the room—cries from an individual much older than your typical pediatric patient. After gently knocking, you enter the room to find an anxious young woman with your actual patient in her arms. This new mother explains what brought her to your emergency department at 3 a.m. After finishing a middle-of-the-night nursing session with her 8-week-old son, she took him to the changing table. As she placed his soiled diaper in the garbage, the infant grew impatient, began kicking and screaming, and his changing pad—which was not secured in place—slid right off the dresser. The mother heard a “thud” as the baby’s head hit the floor after falling approximately 3 feet.

On your initial impression, the child seems to be developmentally appropriate. He is eagerly sucking away on a pacifier and appears content in his mother’s arms. A quick once-over reveals no external signs of trauma. How will you evaluate this child for injury? What are the caveats of examining a non-verbal patient? Is it necessary to obtain imaging for this baby?

Case Study Conclusion:
After taking a deep breath, you proceed with your evaluation of this patient. You systematically address the ABC’s, working your way through the primary and secondary survey. You calculate the Modified Pediatric Glasgow Coma Scale, arriving at a score of 15. You conduct a thorough history and examination, finding no neurological abnormalities. You feel that this patient has no indications for any imaging studies. You explain to the mother that most pediatric head injuries do not result in significant intracranial pathology, and she expresses relief and gratitude.

You explain that the patient will require close follow-up, and the mother informs you that the baby already has a routine 2-month well-child check scheduled for later in the week. After going over discharge instructions with the infant’s mother and outlining signs and symptoms that might warrant concern, you take advantage of this opportunity to discuss with the patient’s mother how this incident might have been prevented. In addition, you review a number of principles of infant home safety with her, and she seems to take your recommendations with appreciation.

Guidelines For The Management Of TIA

Right click the above table and choose “Open in a new window” to view a larger version of this table.