2. • Definition:
– Asthma: Respiratory disease in which the airways become inflamed
causing narrowing and swelling. Also, more mucus is produced
which makes breathing more difficult.
– Exacerbation of asthma: An event during the natural course of
asthma in which the patients baseline dyspnea, cough, and or
sputum is beyond what is normal for the patient on a daily basis.
• Symptoms:
– SOB *
– Anxiety *
– Cough *
– Irregular respiratory patterns *
– Orthopnea
– Yellow or green sputum, hemoptysis
– Chest tightness *
Causes:
– Infection of tracheobronchial tree ( airway inflammation)
– Air pollution (airway inflammation)
– Exercise or stress
– Smoking of any kind
– 1/3 of severe exacerbations cannot be identified
• Diagnosis:
– 4 classes (mild, moderate, severe, life threatening)
– Pulse ox on room air, <92-94 one hour after standard tx =
hospitalization
• Treatment:
– O2 therapy; > 90% saturation
– SABA + Ipratropium by nebulizer/MDI Q20 mins (or continuous
neb)
• Albuterol
– Corticosteroid
• Pulmicort
• Symbicort
• Prognosis:
– Send pt home with systemic corticosteroids.
– Allergen avoidance
WHAT IS EXACERBATION OF ASTHMA?
Medscape.com, aafp.org
3. • 58Yr, African American Female arrives in ER via ambulance on NRB.
• Chief complaint:
– shortness of breath
• Diagnosis: Exacerbation of asthma
• Hx:
– Asthma
– 4 pack year smoking Hx (8 cigarettes a day X 10 yrs)
– CHF
– Multiple hospitalization for exacerbation of asthma
– Used to work at Home Depot for 5 years
– Currently unemployed
PATIENT DATA
4. • Shortness of breath; shallow
• Anxious
• Tachypnic and in severe respiratory distress
• Use of accessory muscles
• Breath sounds: Severe insp/exp wheezing
• Vitals:
– HR: 115, RR: 34, BP: 142/62, Temp: 37.9C, SpO2 90% NRB
• Placed Pt. on 50% venti mask
INITIAL ASSESSMENT
5. • ABG on 50% Venti mask. Uncompensated Respiratory Acidosis
with mild hypoxemia.
– pH 7.25
– PaCO2 65
– PaO2 65
– HCO3- 25
• Critical lab findings only
– Low Calcium: 1.9 mmol/L
– High glucose: 133 mg/dL
– High WBC: 13.5 (13,500/mcL)
LAB FINDINGS
6. • Doctor’s orders (pt in ER)
– 50% venture mask
– Titrate oxygen usage to a minimum
– ABG
– Labs (cbc, electorlytes, lipids)
– 5mg albuterol via aerogen (ultrasonic/mesh nebulizer)
• Administered x2, second dose: 5mg albuterol via aerogen 20 mins after, third dose: 2.5mg albuterol via aerogen 20 mins after second dose.
– Racemic Epinephrine 2.25mg via HHN
– Ativan via IV 2mg.
• Allergies?
• Assessment
– Pt still tachypnic and wheezing after first treatment. Slight tachycardia with HR: 100-105, RR: 30-32.
– 20 mins post second treatment, breath sounds improve, slight expiratory wheeze.
– Ativan administered by nurse, Racemic epinephrine administered via HHN
• During administration of Ativan and racemic epinephrine pt complains of itchy skin and itchy throat.
• Stopped racemic epinephrine treatment.
• Nurse administered Benadryl.
– Patient vitals stable, breath sounds still slight wheeze, pt request to rest. Placed on 4L NC w/ bubble humidifier. Monitor patient status.
DAY 1
7. • Doctor’s orders
– Oxygen therapy keep SpO2 >92%.
– Titrate oxygen usage to minimum
– Duoneb (albuterol 2.5mg/ipratropium bromide 0.5mg in 3ml solution) Q4 via UPA
– Pulmicort 0.5mg BID (1mg max per day)
• Assessment
– Vitals stable: HR: 90, RR 18, BS: slight wheeze bilaterally, BP: 132/70, Tem p 37C.
– No respiratory distress or SOB
– Speaking in full sentences with no signs of distress
– Semi-fowler, non-productive spontaneous cough, sputum: none. Skin is normal, warm, and dry.
– Pt tolerated tx well. Post BS: unchanged, slight wheeze bilaterally.
– Second Q4 tx post BS: improved, clear/diminished bilaterally.
– Decreased nasal cannula from 4L to 2L. Pt. SpO2 99% on 4L. Five minutes post oxygen decrease pt
SpO2 98%. Continue Q4 tx and monitor.
DAY 2
8. • Doctor’s orders
– Oxygen therapy. Keep SpO2 >92%
– Titrate oxygen usage to a minimum
– Titrate down to Room air.
– Duoneb (albuterol 2.5mg/ipratropium bromide 0.5mg in 3ml solution) Q4 via UPA
– Pulmicort 0.5mg BID (1mg max per day)
• Assessment
– Reduced oxygen from 2L NC to Room air. Pt SpO2 99% on 2L. Waited 5 minutes to check
Spo2 Via pulse ox. Room air SpO2 96%.
– Pt looks and sounds great. Speaking in full sentences, smiling and excited to go home.
– Vital signs stable – HR: 76, RR 18, BS: clear and diminished bilaterally, BP: 134/72, Temp:
37.1C
– Upon next Q4 tx discovered patient has been discharged and sent home.
DAY 3
9. Name Class Dosage Indication
Albuterol Bronchodilator 2.5mg in 3ml
solution (mixed
with NL saline)
Bronchospasms,
exacerbation of
asthma.
Duoneb Bronchodilator 2.5 mg
albuterol/0.5 mg
atrovent
Bronchospasms,
wheezing.
Racemic
Epinephrine
Vasopressor 2.25%/0.5 ml Chest tightness,
wheezing.
Pulmicort Corticosteroids 0.5 mg BID Maintenance Tx
of asthma.
Ativan Benzodiazapines 2mg via IV Anti-anxiety.
MEDICATION LIST
www.drugs.com
10. • Maintain SpO2 > 92%
• Achieve patent airway and maintain airway clearance
– Bronchodilator and oxygen therapy
• Recommend avoiding irritants such as pollen, air pollution, cigarette smoke or any
others that might trigger an asthma attack.
• Send patient home with peak flow
• Send patient home with prescriptions for bronchodilator therapy.
• Day 1 suggestions:
– Instead of trying three treatments of albuterol every 20 minutes, why not try a continuous neb
treatment? And monitor patient during treatment?
• Day 2&3 suggestions:
– After recording breath sounds as clear/diminished, change Q4 to Q6? Or change it to Q4PRN?
RECOMMENDATIONS AND PLAN OF CARE
11. • Patient arrives in ED via ambulance, 4 pack year smoking hx, and hx of CHF
– Respiratory distress
– Tachypnic
– Tachycardic
– Anxious
– Increased WOB
– SOB
– Severe insp/exp wheezing
– ABG results: Uncompensated Respiratory Acidosis with mild hypoxemia
• Day 1
– Placed on 50% venture mask, ABG, LABS, Albuterol, Racemic Epinephrine, and Ativan treatments.
– Pt. allergic reaction to Ativan (racemic epi?)
• Benadryl administered by RN
– Breath sounds improved to moderate wheezing from severe, monitor patient.
• Day 2/3
– Titrate oxygen use down, but keep SpO2 > 90%
– Pt. now on 4/2L NC SpO2 96-98%
– Duoneb and Pulmicort
– Vitals stable, BS improving to mild wheezing and clear/diminished.
• Sent patient home with bronchodilator treatments, and educated patient to prevent asthma attacks by avoiding irritants and other
triggers.
OVERALL SUMMARY AND CONCLUSION
