Pharmacotherapy Case: Acute Asthma Exacerbation by Dr. Nehad Jaser

 Subjective Data:

A 25-year-old female presents to the emergency department with a 24-hour history of worsening dyspnea, wheezing, and chest tightness. She reports increased use of her albuterol inhaler (6–8 puffs every 3–4 hours) with minimal relief. She notes a non-productive cough and states she ran out of her maintenance inhaler (fluticasone/salmeterol) one week ago. She has a history of childhood asthma, triggered by upper respiratory infections (URIs) and pet dander. She recently recovered from a mild URI. Denishes fever, sputum production, or recent travel.

Objective Data:

• Vital Signs:

  • BP: 132/84 mmHg

  • HR: 110 bpm (tachycardia)

  • RR: 28/min (tachypnea)

  • Temp: 98.6°F (37°C)

  • SpO2: 92% on room air

• Physical Exam:

  • Respiratory: Diffuse expiratory wheezing, prolonged expiratory phase, use of accessory muscles.

  • No jugular venous distension or cyanosis.

• Diagnostics:

  • Chest X-ray: Hyperinflation, no infiltrates.

  • ABG (room air): pH 7.48, PaCO2 32 mmHg, PaO2 72 mmHg (mild hypoxemia, respiratory alkalosis).

  • Peak Flow: 55% of personal best (noted retrospectively; patient typically averages 380 L/min, now 210 L/min).

Assessment:
Acute Asthma Exacerbation (Moderate-Severe)

• Likely triggered by non-adherence to maintenance therapy and recent URI.

• Exacerbation severity indicated by increased work of breathing, frequent SABA use, and reduced peak flow.

Pharmacotherapy Plan:

1. Immediate Management:

   • Oxygen: 2–4 L/min via nasal cannula to maintain SpO2 ≥94%.

   • Nebulized Short-Acting Beta Agonist (SABA): Albuterol 2.5 mg + Ipratropium 0.5 mg nebulized every 20 minutes × 3 doses.

   • Systemic Corticosteroids: Methylprednisolone 125 mg IV once, then transition to oral prednisone 40 mg daily for 5 days.

   • Monitoring: Repeat vital signs and peak flow after initial treatments.

2. Reassessment at 2 Hours:

   • Improved SpO2 (96%), RR 18/min, HR 88 bpm, peak flow 280 L/min. Wheezing decreased but persists.

3. Discharge Plan:

   • Corticosteroids: Prednisone 40 mg daily × 5 days.

   • Maintenance Therapy: Resume fluticasone/salmeterol 250/50 mcg 1 inhalation twice daily.

   • Rescue Inhaler: Albuterol MDI (with spacer) 2 puffs every 4–6 hours as needed.

   • Education:

     • Reinforce adherence to ICS-LABA.

     • Instruct on inhaler technique and asthma action plan.

     • Avoid triggers (e.g., pet dander, URIs).

   • Follow-Up: Primary care physician in 7 days; consider allergist referral.

Rationale:

• SABA + ipratropium rapidly reverses bronchoconstriction.

• Systemic steroids reduce airway inflammation and prevent relapse.

• ICS-LABA maintenance therapy is critical for long-term control.

Outcome:
Patient discharged with improved symptoms. Emphasized the importance of adherence to prevent future exacerbations.