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.