Pharmacotherapy Case: Acute Asthma Exacerbation / Dr. Nehad Ahmed

 

Pharmacotherapy Case: Acute Asthma Exacerbation

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Patient Information:

• Age: 28
• Gender: Female
• Date of Visit: February 5, 2025

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Chief Complaint:

"Shortness of breath, wheezing, and chest tightness for the past few hours."

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Subjective Data:

• History of Present Illness: The patient is a 28-year-old female with a known history of asthma, presenting with worsening symptoms of acute shortness of breath, chest tightness, and wheezing for the last 3 hours. The symptoms began suddenly while the patient was exposed to cold air while outside. She has been using her albuterol inhaler more frequently but reports minimal relief. The patient denies any recent upper respiratory infections, fever, or known exposure to allergens or triggers.

• Past Medical History:

  • Asthma, diagnosed at age 10
  • Seasonal allergic rhinitis
  • No history of severe asthma exacerbations requiring intubation or ICU admission
  • No significant comorbidities (e.g., diabetes, hypertension)

• Current Medications:

  • Albuterol inhaler (90 mcg/puff) for rescue use, typically every 4-6 hours when needed
  • Fluticasone propionate inhaler (110 mcg), 1 puff daily for maintenance asthma control
  • Loratadine 10 mg daily for allergies

• Allergies:

  • No known drug allergies
  • Seasonal pollen allergies

• Family History:

  • Mother has asthma
  • Father has seasonal allergies

• Social History:

  • Non-smoker
  • No alcohol use
  • Works a desk job, sedentary lifestyle
  • No recent travel or known sick contacts

• Review of Systems:

  • Respiratory: Shortness of breath, wheezing, non-productive cough, chest tightness
  • Cardiovascular: No chest pain, palpitations, or swelling
  • Gastrointestinal: No nausea, vomiting, or abdominal discomfort
  • Neurological: No dizziness or headaches

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Objective Data:

• Vital Signs:

  • Temperature: 98.6°F (37°C)
  • Blood Pressure: 128/82 mmHg
  • Heart Rate: 110 bpm (tachycardia)
  • Respiratory Rate: 22 breaths per minute (tachypnea)
  • Oxygen Saturation: 94% on room air

• Physical Examination:

  • General Appearance: Patient appears mildly distressed, with labored breathing
  • HEENT: No nasal congestion, no signs of sinus infection, no throat redness
  • Chest and Lungs:
    • Inspection: Use of accessory muscles, increased work of breathing
    • Palpation: No tenderness
    • Percussion: Normal resonance
    • Auscultation: Wheezing noted throughout both lung fields, especially during exhalation. No crackles or rhonchi.
  • Cardiovascular: Regular rhythm, tachycardic with a heart rate of 110 bpm. No murmurs or edema.
  • Abdomen: Soft, non-tender, no signs of distension or abnormal bowel sounds
  • Extremities: No cyanosis or edema, good peripheral pulses

• Peak Flow Measurement:

  • Forced Expiratory Volume (FEV1) at 45% of predicted normal value, consistent with moderate obstruction.

• Arterial Blood Gas (ABG):

  • pH: 7.38
  • pCO2: 35 mmHg
  • pO2: 70 mmHg
  • HCO3: 22 mEq/L
  • O2 saturation: 94%

• Chest X-ray:

  • No consolidation, pneumonia, or significant changes observed. Mild hyperinflation suggestive of asthma.

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Assessment:

The patient is experiencing an acute asthma exacerbation likely triggered by environmental factors (cold air exposure). Objective findings, including wheezing, increased work of breathing, and decreased peak flow, support this diagnosis. The patient demonstrates moderate airflow obstruction, as evidenced by a reduced FEV1 and oxygen saturation at 94%, indicating a need for urgent treatment and management.

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Plan:

1. Short-acting Beta-Agonist (SABA):

   • Administer albuterol 2.5 mg nebulized every 20 minutes for up to 3 doses to provide rapid bronchodilation.

2. Corticosteroids:

   • Initiate oral prednisone 40 mg daily for 5-7 days to reduce airway inflammation.

3. Inhaled Anticholinergic (Optional):

   • Administer ipratropium bromide (Atrovent) 0.5 mg nebulized every 20 minutes for the first 1-2 hours as adjunct therapy if the response to albuterol is inadequate.

4. Oxygen:

   • Administer supplemental oxygen to maintain O2 saturation > 94%. If necessary, adjust the flow rate to keep O2 saturation between 94-98%.

5. Monitoring:

   • Continuous monitoring of respiratory rate, oxygen saturation, and work of breathing. Monitor peak flow rates to assess improvement in lung function.

6. Discharge Planning:

   • Once symptoms improve, and peak flow is > 70% of the predicted value, consider discharge with instructions to:
     • Continue albuterol inhaler as needed every 4-6 hours until symptoms resolve.
     • Follow up with primary care physician within 1-2 days.
     • Instruct on proper inhaler technique and the use of a spacer if needed.
     • Educate about avoiding known triggers (e.g., cold air) and recognize early signs of exacerbation for prompt management.

7. Referrals:

   • Referral to a pulmonologist if exacerbations are frequent or poorly controlled.

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Follow-up:

• Return to the clinic in 1-2 days for a follow-up visit if symptoms persist or worsen.