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 Case
#14 Don’t take her breath away
A 21 y/o female with a history of asthma presents in acute bronchospasm. She has a history of previous asthma attacks requiring admission, but no ICU admissions and no Intubations. Her last ED visit was 8 months ago, and she stayed in the hospital then for a few days. Her medications include Advair (Fluticasone and Salmeterol) and an Albuterol (Salbutamol) inhaler (but she confesses she sometimes uses her Advair if she can’t find the albuterol and she feels short of breath). She also takes birth control pills. She has been afebrile, but has a dry cough (no sputum). She also has sharp chest pain when she coughs (substernal), and denies any abdominal complaints. She only has a past history of asthma. She does not smoke.
Physical exam reveals RR = 28, HR =110, BP = 135/80, T=98 F, and Sat 90% on RA. She is working hard at breathing, has accessory muscle use, but can answer with simple sentences. HEENT is unremarkable, heart is tachy without Murmurs. Lungs reveal prolonged exp phase with expiratory wheezing throughout. Air movement is diminished. Abdominal exam is unremarkable, as is the rest of her exam.
The nurse places her on a monitor, initiates IV access, places her on 4 L NC oxygen (Sat increases to 95%), and undresses her. You order an albuterol and atrovent (Ipratropium) inhalation treatment, and also order 125 mg of Solumederol (methyprednisolone). After this treatment she is improved, but still working hard to breathe.
1. What other pharmacologic interventions should you consider?
2. What do you think of her using her Advair when she doesn’t have the Albuterol?
3. Is there a role for BiPap?
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