Case 2

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Learning Objectives
After completing this case study, the reader should be able to: Recognize the signs and symptoms of an acute asthma exacerbation. Formulate therapeutic endpoints based on the initiation of a pharmacotherapy plan used to treat the acute asthma symptoms. Identify appropriate dosage form selection based on the patient's age, ability to take medication, or adherence to technique. Determine an appropriate home pharmacotherapy plan, including discharge counseling, as the patient nears discharge from a hospital setting.
PATIENT PRESENTATION Chief Complaint

"My daughter has had a bad fever, and now she is having trouble breathing and albuterol doesn't help."
HPI
Terri Collins is an 8-year-old African-American girl who presents to the emergency department with a 2-day history of fevers, malaise, and nonproductive cough. The mother gave acetaminophen and ibuprofen to help control the fever. Mother stated that "a lot of other kids in her class have been sick this fall, too." Terri started having trouble breathing the morning of admission, and the mother gave her albuterol, 2.5 mg via nebulization twice within an hour. Terri still sounded wheezy to the mother after the albuterol, and Terri stated it was "hard to breath." Terri was previously well controlled regarding asthma symptoms. Previous clinic notes reported symptoms during the day only with active play at school or at home and rare nighttime symptoms. She uses prn albuterol to help with symptoms after playing. Her assessment in the emergency department revealed Terri to have labored breathing, such that she could only complete four- to five-word sentences. She had subcostal retractions, tracheal tugging with tachypnea at 54 breaths/min. Her other vital signs were a heart rate of 160 beats/min, blood pressure of 115/59, temperature of 38.8C, and a weight of 22.7 kg. The initial oxygen saturation was 88%, and she was started on oxygen at 3 L/min via nasal cannula. Bilateral expiratory and inspiratory wheezes were noted on examination. A chest x-ray revealed a right lower lobe consolidation consistent with pneumonia and possible
effusion. After receiving three albuterol/ipratropium nebulizations, her breath sounds and oxygenation did not improve, so she was started on hourly albuterol nebulizations at 5 mg. She was also given a dose of 25 mg IV methylprednisolone and a dose of 600 mg IV magnesium sulfate. Terri was then transferred to the Pediatric Intensive Care Unit for further treatment and monitoring.
PMH
Asthma, last hospitalization 4 years ago, and last course of oral corticosteroids over a year ago
FH
Asthma on dad's side of the family
SH
Lives with mother, father, and two siblings, both of whom have asthma. There are two cats and a dog in the home. Father is a smoker, but states that he tries to smoke outside and not around the kids. She is in the second grade and is very active on the playground.
Meds
Albuterol 2.5 mg nebulized Q 46 h PRN wheezing Fluticasone 44 mcg MDI two puffs BID Acetaminophen 160 mg/5 mL10 mL PRN fever Ibuprofen 100 mg/5mL10 mL PRN fever
All
NKA
ROS
(+) Fever, cough, increased work of breathing
Physical Examination
GEN
Alert and oriented but in mild distress with difficulty breathing
VS
BP 125/69, P 120, T 37.9C, R 40, O2 sat 94% on 3 L/min nasal cannula
SKIN
No rashes, no bruises
HEENT
NC/AT, PERRLA
NECK/LN
Soft, supple, no cervical lymphadenopathy
CHEST
Wheezes throughout all lung fields, still with subcostal retractions
CV
RRR, no m/r/g
ABD
Soft, NT/ND
EXT
No clubbing or cyanosis
NEURO
A & O, no focal deficits
Labs
Na 141 mEq/L K 3.1 mEq/L Cl 104 mEq/L CO2 29 mEq/L BUN 16 mg/dL WBC 34.2 x 103/mm3 Neut 91% Lymph 5% Mono 4% RBC 5.07 x 106/mm3
SCr 0.52 mg/dL Hgb 13 g/dL Glu 154 mg/dL Hct 41% Plt 310 x 103/mm3 Respiratory viral panel nasal swab: positive for influenza A (probably H1N1 strain)
Chest X-Ray
RLL consolidation
Assessment
Asthma exacerbation with viral pneumonia
CLINICAL PEARL
For proper treatment of an acute asthma exacerbation, the patient (or family) needs to be aware of the first symptoms of an exacerbation and possible triggers. At this point, the patient (family) should initiate their asthma action plan to minimize the symptoms, duration of drug therapy, and severity of the exacerbation. This, in turn, should decrease
the number of severe exacerbations and hospital admissions.
REFERENCES
1. National Asthma Education and Prevention Program Expert Panel report 3: guidelines for the diagnosis and management of asthma. Bethesda, MD, National Institutes of Health, 2007. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm. Accessed March 16, 2010. 2. Aldington S, Beasley R. Asthma exacerbations 5: assessment and management of severe asthma in adults in hospital. Thorax 2007;62:447458. 3. Andrew T, McGintee E, Mittal MK, et al. High-dose continuous nebulized levalbuterol for pediatric status asthmaticus: a randomized trial. J Pediatr 2009;155:205 210. 4. Rodrigo GJ, Castro-Rodriguez JA. Anticholinergics in the treatment of children and adults with acute asthma: a systematic review with meta-analysis. Thorax 2005;60:740 746. 5. Rowe BH, Camargo CA. The role of magnesium sulfate in the acute and chronic management of asthma. Curr Opin Pulm Med 2008;15:7076. 6. Cheuk DKL, Chau TCH, Lee SL. A meta-analysis on intravenous magnesium sulphate for treating acute asthma. Arch Dis Child 2005;90:7477. 7. Hendeles L. Selecting a systemic corticosteroid for acute asthma in young children. J Pediatr 2003;142:S40S44. 8. Rank MA, Li JT. Clinical pearls for preventing, diagnosing, and treating seasonal and 2009 H1N1 influenza infections in patients with asthma. J Allergy Clin Immunol 2009;124:11231126.
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PATIENT PRESENTATION Chief Complaint

Soft, supple, no cervical lymphadenopathy

the number of severe exacerbations and hospital admissions.

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