A 58-year-old African American female presented to the emergency room experiencing shortness of breath due to an exacerbation of asthma. Initial assessments found respiratory distress, wheezing, and uncompensated respiratory acidosis. Treatment included oxygen, nebulizers, steroids, and benzodiazepines. Over three days, the patient's condition improved with clear breath sounds and stable vitals on low-flow oxygen. She was discharged home with medications and education to prevent future exacerbations.

1. Bryan Abadilla, SRT
ACC, ONT RT-13
EXACERBATION OF ASTHMA

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

12. • http://www.medscape.com/viewarticle/707497_2
• http://www.webmd.com/lung/10-signs-copd-exacerbation
• http://www.drugs.com
RESOURCES