A 25-year-old man comes to the emergency department due to dry cough, wheezing, and congestion. The patient says his symptoms have been worsening over the past 3 days; he has no fever or chills. Medical history includes well-controlled asthma and no hospitalizations. The patient says normally he uses his reliever inhaler only as needed, usually 3 or 4 times a year, but it has not relieved his symptoms during this episode. Temperature is 37.1 C (98.8 F), blood pressure is 138/78 mm Hg, pulse is 112/min, and respirations are 24/min. Oxygen saturation is 95% on room air. Diffuse wheezing is noted on examination. The patient is appropriately treated and says he feels much better 2 hours later. On reexamination, respirations are 18/min, oxygen saturation is 99% on room air, and the wheezing has decreased. The patient would like to go home. In addition to optimizing his rescue inhaler therapy, which of the following medications is indicated on discharge to promote resolution of this patient's exacerbation?

Question

A 25-year-old man comes to the emergency department due to dry cough, wheezing, and congestion.  The patient says his symptoms have been worsening over the past 3 days; he has no fever or chills.  Medical history includes well-controlled asthma and no hospitalizations.  The patient says normally he uses his reliever inhaler only as needed, usually 3 or 4 times a year, but it has not relieved his symptoms during this episode.  Temperature is 37.1 C (98.8 F), blood pressure is 138/78 mm Hg, pulse is 112/min, and respirations are 24/min.  Oxygen saturation is 95% on room air.  Diffuse wheezing is noted on examination.  The patient is appropriately treated and says he feels much better 2 hours later.  On reexamination, respirations are 18/min, oxygen saturation is 99% on room air, and the wheezing has decreased.  The patient would like to go home.  In addition to optimizing his rescue inhaler therapy, which of the following medications is indicated on discharge to promote resolution of this patient's exacerbation?

Quizplus · Accepted Answer

11ec25c8_d129_3b83_bc81_b121a72606a9_MD0003_00 An acute asthma exacerbation is defined as an acute worsening of symptoms (eg, cough, wheezing, dyspnea) accompanied by a significant decline in expiratory flow rate. Acute exacerbations occur when sensitized bronchioles are exposed to a trigger (eg, respiratory tract infection, allergens), causing mast cell degranulation. In the immediate phase (minutes to hours) of an acute asthma exacerbation, release of preformed mediators (histamine, leukotriene) causes immediate bronchoconstriction, airway edema, and mucus production. Initial treatment of an acute asthma exacerbation focuses on relaxing bronchoconstriction with a short-acting beta agonist (eg, albuterol), a short-acting muscarinic antagonist (eg, ipratropium), and intravenous magnesium. Hours after the immediate response, a late-phase reaction occurs, characterized by proinflammatory gene expression, de novo synthesis of T_H2 cytokines, and further recruitment of leukocytes, all contributing to ongoing bronchospasm and inflammation. Systemic glucocorticoids (eg, oral prednisone, dexamethasone) reduce late-phase inflammation. late-phase reaction _H Because the anti-inflammatory activity of glucocorticoids is delayed by several hours (due to the time required to change nuclear gene expression), they are often given with bronchodilators in the emergency department. Corticosteroids are continued at home (eg, prednisone 40-60 mg daily for 5-7 days) to prevent relapse and decrease the need for hospitalization (Choice B). (Choice A) Bronchial smooth muscle relaxation (eg, via albuterol, ipratropium) can improve airflow in the short-term but does not sufficiently treat the underlying airway inflammation and edema during an acute asthma exacerbation. (Choice C) Antibiotics are not routinely indicated for asthma exacerbations unless there is evidence for an underlying lower respiratory tract infection (eg, fever, purulent sputum, rales, egophony). Macrolide antibiotics (eg, azithromycin) can improve recovery in some patients with acute exacerbations of chronic obstructive pulmonary disease, partially because they inhibit neutrophil-mediated airway inflammation. In multiple clinical trials, macrolides provided no benefit for acute asthma exacerbations, which are driven by eosinophil-mediated airway inflammation. (Choice D) An oral antihistamine (eg, H₁ receptor antagonist) is used to treat allergic rhinitis. Although allergic rhinitis can trigger an asthma exacerbation, antihistamines do not have a role in acute asthma management. Educational objective: Treatment of an acute asthma exacerbation includes a short-acting bronchodilator to manage immediate bronchoconstriction and a systemic glucocorticoid (eg, prednisone) to dampen late-phase inflammation and prevent symptom relapse. References: Asthma exacerbations: pathogenesis, prevention, and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/28689842)

A 25-Year-Old Man Comes to the Emergency Department Due to Dry