An 8-year-old male presents to the emergency room with acute shortness of breath likely due to an asthma exacerbation. His symptoms have been worsening over the past 24 hours. On examination, he has increased work of breathing and wheezing. Arterial blood gas shows respiratory acidosis. He is started on nebulized bronchodilators and steroids to treat the exacerbation. A 24-year-old male presents to clinic with worsening cough, wheezing, and dyspnea over the past 3 days in the setting of an upper respiratory infection. Examination reveals wheezing. He is diagnosed with an asthma exacerbation from his upper respiratory symptoms and started on inhaled

1. ASTHMA
Dorian Matzen, PGY-2
Family Medicine
May 21st
, 2015

2. THE BASIC ASSUMPTION OF MEDICAL
EDUCATION
We believe that everyone participating is intelligent,
interested, well-trained, cares about doing their best and
wants to improve.

3. Case 1 – Acute Shortness of breath
C/C SOB
An 8 Y/O male presents to ER for acute respiratory distress. Mother is present,
states that he had been having increased dyspnea over the past 24 hours, was
breathing fast after coming home from school. Has been using his inhaler
frequently. He didn’t eat much dinner last night or breakfast this morning has
been coughing non-stop and has vomited x2, normal emesis. No recent sick
contacts, it is springtime in Elmira and it has been warm weather and there has
been a significant pollen count over the past several days. No fever reported,
grossly audible wheezing and apparent respiratory distress with tachypnea and
increased WOB.
Very High High Extreme Low

4. PMHx: Asthma
HoMeds: Albuterol MDI, Advair diskus 100/50mcg
All: NKDA
PSHx: None
SocHx: Lives with single parent and 7 siblings
FamHx: Father - childhood asthma
Vaccinations are up to date
Case 1 – Acute Shortness of breath

5. PE:
VS: T-99.7F, HR-190, RR-66, BP-126/75, 86% O2 sat initially, now 91% on Simple
mask with continuous albuterol via large volume nebulizer, wt: 62lbs
Gen: WDWN 8 Y/O male in severe distress 2/2 asthma exacerbation
HEENT: NCAT, EOMI, PERRLA @5mm, oral mucosa slightly dry, no thrush
Neck: +suprasternal retractions, No tracheal deviation, no thyromegaly, no
anterior/posterior cervical, submandibular or supraclavicular lymphadenopathy
Chest: +intercostal retraction, notable increased WOB of muscles of respiration,
+expiratory wheezing, prolonged expiratory phase.
Abd: Soft, NTND, hypoactive bowel sounds, no guarding, no rebound
GU: Grossly normal male, circumcised, Tanner stage I, both testes descended
MSK: Good UE and LE tone, able to move all extremities
Skin: No rashes or bruising noted on trunk or extremities
Neuro: A&O x3 (person, place, date), +2/4 patellar and brachioradialis reflexes b/l
Lymph: no anterior/posterior cervical lymphadenopathy, no axillary lymphadenopathy
Extremities: no clubbing, no cyanosis, no nail stippling
Osteopathic: Posterior paraspinal muscular tension in T1-T5 +ropey texture bilaterally,
Left ribs 4-7 stuck in inhalation.
Case 1 – Acute Shortness of breath

6. Labs:
CMP:
CBC:
ABG: 7.33pH, 71PaO2, 21HCO3, 34PaCO2, BE: -4
Blood culture x2 pending
Viral Panel pending
UA: essentially negative
97
137 101 22
4.2 36 0.7
8.8
13.7
7.7 332
43.4
???

10. An 8 Y/O male presents to ER for acute SOB, ongoing for the past 24hrs,
likely asthma exacerbation given past medical history of Asthma. Pt.
responding with limited improvement to nebulized medications,
continued dyspnea with persistently increased work of breathing.
Assessment:
Plan:
#1) Asthma Exacerbation – Acute
- Albuterol and Ipratropium (Duonebs) q4hr
- Methylprednisolone IVP 30mg IVP BID (1-2mg/kg/day)
- Initial Spirometry and serial PEFs to monitor resolution
- Asthma control assessment, Asthma Action Plan

14. THE 4 STAGES OF BLOOD GAS PROGRESSION IN PERSONS WITH
STATUS ASTHMATICUS ARE AS FOLLOWS:
STAGE 1 - CHARACTERIZED BY HYPERVENTILATION WITH A
NORMAL PARTIAL PRESSURE OF OXYGEN (PO 2)
STAGE 2 - CHARACTERIZED BY HYPERVENTILATION
ACCOMPANIED BY HYPOXEMIA (IE, A LOW PARTIAL PRESSURE OF
CARBON DIOXIDE [PCO 2] AND LOW PO 2)
STAGE 3 - CHARACTERIZED BY THE PRESENCE OF A FALSE-
NORMAL PCO 2; VENTILATION HAS DECREASED FROM THE
HYPERVENTILATION PRESENT IN THE SECOND STAGE; THIS IS AN
EXTREMELY SERIOUS SIGN OF RESPIRATORY MUSCLE FATIGUE
THAT SIGNALS THE NEED FOR MORE INTENSIVE MEDICAL CARE,
SUCH AS ADMISSION TO AN ICU AND, PROBABLY, INTUBATION
WITH MECHANICAL VENTILATION.
STAGE 4 - CHARACTERIZED BY A LOW PO 2 AND A HIGH PCO 2,
WHICH OCCURS WITH RESPIRATORY MUSCLE INSUFFICIENCY;
THIS IS AN EVEN MORE SERIOUS SIGN THAT MANDATES
INTUBATION AND VENTILATORY SUPPORT.
Status Asthmaticus workup, Medscape
http://emedicine.medscape.com/article/2129484-workup#aw2aab6b5b4

15. Recommended doses of medications to treat children with an asthma exacerbation
Albuterol (Salbutamol) 0.15mg/kg per dose, 2.5mg min., 5.0mg max every 20 to
30 minutes for 3 doses
Continuous is 0.5mg/kg (max 20mg/hr) by LVN
5 - 10kg --- 7.5mg/hr
10-20kg --- 11.25mg/hr
>20kg --- 15mg/hr
MDI w/spacer 1/3 – 1/4 puff per kg or 4-8 puffs q20-30min for x3 doses, then
every 1-4hrs as needed. Add a mask for children less than 4 Y/O.
Levalbuterol – 1/2 the recommended dose for racemic albuterol
The SABAs – Short Acting Beta-2 Agonists

16. Recommended doses of medications to treat children with an asthma exacerbation
Ipratropium (Atrovent) <20kg – 250 mcg/dose, q20 min for x3 doses
nebulizer solution ≥20kg – 500 mcg/dose
multidose inhaler 18mcg/puff
4-8 puffs q20min PRN for 3hrs

18. Recommended doses of medications to treat children with an asthma exacerbation
Systemic glucocorticoids:
Prednisone or Prednisolone – 1 to 2 mg/kg PO (max 60mg/day), then 0.5 to
1mg/kg twice daily for subsequent doses,
typically 3-10 day course.
Methylprednisolone - 1 to 2mg/kg (max 125mg/day) IV
Dexamethasone - 0.6mg/kg (max 16mg/day) PO, IM or IV

20. Recommended doses of medications to treat children with an asthma exacerbation
Systemic beta-2 agonists
Epinephrine - 0.01mg/kg IM or SQ (Max 0.4mg/dose)
may be repeated x3 q10-20min
- OR -
Terbutaline - 0.01mg/kg SQ or IM (Max 0.25mg/dose)
may be repeated x3 q20min, then q2-6hrs PRN
Other Treatment
Magnesium Sulfate – 25 to 75 mg/kg IV (Max 2g)
infuse over 20 minutes
a metastudy showed an ARR of 0.26
the endpoint being hospitalization.
4

22. When I was up in Rochester…

25. Spirometry/Peak Flows

27. POISEUILLE'S LAW

30. Even though asthma is a prevalent disease, annual per capita mortality from
asthma is relatively low worldwide, ranging from 1.51 per million population in
the United Kingdom to 13.66 in the United States, 25.56 in Japan, 31.6 in
Germany, and 86.92 in South Korea
Asthma epidemiology

31. Case 2 – The clinic visit
HPI: A 24 Y/O male presents to clinic acutely complaining of cough, wheezing,
runny nose and dyspnea. He states that his hearing has been “like he is under water”
since this morning. He reports that has been using his albuterol inhaler more
frequently over the past 3 days, up to every 2-4 hours on average. He was only
recently diagnosed with Asthma 3 months ago and was started on an Albuterol MDI
inhaler, which he reports was controlling his asthma well and had been only using
his inhaler 1-2 times/day. The patient states that he has stopped running his daily 3-5
miles and is concerned about staying on track for his 10k run in June.

32. Case 2 – The clinic visit
PMHx: Asthma
Meds: Albuterol MDI
All: ASA
PSHx: Adenoid/Tonsillectomy
FamHx: Father – DM II, HTN, Emphysema; Mother – HLD, Asthma-COPD
SocHx: Social alcohol, 1-2 drinks/week, Non-smoker, never smoked,
no illicit drugs, works as a new car salesman
Vaccinations: Completed childhood and pre-college vaccinations.

33. Case 2 – The clinic visit
VS: T-98.8F, HR-88, RR-20, BP-118/74, 95% O2 sat on R/A, Wt. 174lbs, Ht-5’10”
Gen: 24 Y/O WDWN male in NAD
HEENT: NCAT, PERRLA @5mm, oral mucosa moist, some serous fluid noted
behind tympanums without any injection or erythema, no tonsilar exudate, no
posterior oropharyngeal cobblestoning, some noted erythema and mild edema of the
nares bilaterally, some clear drainage noted as well.
Neck: no thyromegaly, trachea midline
CV: S1S2 noted, RRR, = radial pulses bilaterally
Pulm: Lungs have notable diffuse expiratory wheezing, expiratory phase not notably
prolonged, no rhonchi or rales noted
Abd: Soft, NTND, normoactive bowel sounds
Skin: no rashes or bruises noted
Extremities: no clubbing or cyanosis noted
Neuro: CN II-XII grossly intact, Pt. A&O to person, place, date
Psych: alert and appropriate to questions, no blunted affect
Lymph: some + shotty posterior cervical lymphadenopathy, no anterior cervical,
submandibular or supraclavicular lymphadenopathy.
Osteopathic: Some noted upper cervical paraspinal muscular tension

34. Case 2 – The clinic visit
Assessment: 24 Y/O male presents to clinic with moderate persistent asthma
with 3 day history of URI symptoms provoking an asthma exacerbation,
frequent daily MDI SABA use and increased fatigue.
Plan:
1) Asthma exacerbation – Acute; Advair MDI Fluticasone &
Salmeterol) 45/21mcg, 2 inhalations BID, In-office nebulizer
treatment with albuterol-ipratropium, in-office spirometry (if
available), PEF evaluation prior to and after nebulizer treatment,
Consider Allergy referral for skin allergen testing if no
improvement, F/U in 2 weeks for resolution of URI, adherence to
new therapy.
2) URI – Likely viral, will given sinus toileting regimen of Ocean
nasal spray 4x daily, Flonase (Fluticasone) 2 sprays per nostril qd,
benedryl 25mg PO qhs

35. Goals of Asthma Management
1) Routine monitoring, ie clinic visits
2) Patient education
3) Controlling environmental risk factors that increase severity
4) Pharmacologic therapy
Goals of Asthma Treatment
1) Reduce Impairment
-Freedom from frequent or troublesome symptoms
-Minimize need for SABAs to ≤2 days/week
-Minimize night-time dyspnea awakenings to <2 nights/month
-Optimize lung function
-Maintenance of normal activites: school, work, athletics
-Satisfaction with asthma care by Pt. and her family
2) Reduce Risk
-Prevent recurrent hospitalizations and ER visits/hospitalization
-Prevent reduced lung growth in children and loss of function in
adults
-Optimize pharmacotherapy with minimal/no side effects

36. Assessment of Impairment
-Nighttime awakenings
-Frequency of SABA MDI usage
-Unscheduled care for asthma, Urgent care or ER visits
-Participation in life activities: work, school, athletics
-Peak expiratory flow measurements, monitoring and reduction in best PEF
-Side effects of medications
Assessment of Risk
-Monitoring adherence with inhaled glucocorticoids
-Taking any oral glucocorticoids in the past year
-Hospitalized in the last year? How many times?
-Currently smoking?
-Worsening of asthma symptoms with ASA or NSAIDS?

38. The STEPS approach to Asthma Control

53. The Methylated Xanthines

54. The Purine Salvage Pathway

57. Question 2
A 24 year-old woman with persistent asthma, which is well controlled on low-
dose fluticasone and albuterol as needed, became pregnant 2 months ago and
asks for advice about asthma therapy during her pregnancy. Before she started
fluticasone therapy, she had frequent asthma symptoms and occasional
exacerbations requiring emergency department treatment. Since she became
pregnant, her asthma has remained under good control. The physical
examination is un remarkable and spirometry is normal.
Which of the following is the most appropriate management for this patient?
A)Continue the current regimen
B)Stop Fluticasone; add theophylline
C)Stop Fluticasone; add salmeterol
D)Stop Fluticasone; add inhaled cromolyn

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MD
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Gregory Sawicki MD MPH, Kenan Haver MD, Robert Wood MD, Gregory Redding MD
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64. Asthma in children younger than 12 years: Initial evaluation and diagnosis; UpToDate;
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Status Asthmaticus workup, Medscape
http://emedicine.medscape.com/article/2129484-workup#aw2aab6b5b4

65. Medical Physiology And Pathophysiology, Essentials and clinical problems
http://www.zuniv.net/physiology/book/chapter13.html
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