A 27-year-old man comes to the emergency department with sudden onset of shortness of breath. He ran out of his asthma medication 10 days ago. He has been intubated twice in the past 6 months due to severe asthma exacerbations. On physical examination, his temperature is 37.2 C (99 F), blood pressure is 142/64 mm Hg, heart rate is 110/min, and respirations are 28/min. His oxygen saturation is 84% on room air and improves to 94% on nonrebreather mask. The patient is alert but appears to be in respiratory distress with some use of accessory muscles of respiration. His lung examination shows equal, bilateral air entry with diffuse wheezing throughout both lung fields. His peak expiratory flow rate is 60% of his personal best, based on his prior admissions. While in the emergency department, the patient's respirations become more labored. He is now markedly diaphoretic and has visible suprasternal retractions. He appears exhausted and drowsy. Repeat vital signs are temperature of 37.2C (99 F), blood pressure of 110/74 mm Hg, pulse of 106/min, and respirations of 10/min. His oxygen saturation is 95% on nonrebreather mask. Lung examination shows bilaterally equal but markedly reduced air entry with minimal wheezing on both sides. The patient is not able to follow instructions to use the peak flow meter. Which of the following is the most important next step in management?

Question

A 27-year-old man comes to the emergency department with sudden onset of shortness of breath.  He ran out of his asthma medication 10 days ago.  He has been intubated twice in the past 6 months due to severe asthma exacerbations.  On physical examination, his temperature is 37.2 C (99 F), blood pressure is 142/64 mm Hg, heart rate is 110/min, and respirations are 28/min.  His oxygen saturation is 84% on room air and improves to 94% on nonrebreather mask.  The patient is alert but appears to be in respiratory distress with some use of accessory muscles of respiration.  His lung examination shows equal, bilateral air entry with diffuse wheezing throughout both lung fields.  His peak expiratory flow rate is 60% of his personal best, based on his prior admissions. While in the emergency department, the patient's respirations become more labored.  He is now markedly diaphoretic and has visible suprasternal retractions.  He appears exhausted and drowsy.  Repeat vital signs are temperature of 37.2C (99 F), blood pressure of 110/74 mm Hg, pulse of 106/min, and respirations of 10/min.  His oxygen saturation is 95% on nonrebreather mask.  Lung examination shows bilaterally equal but markedly reduced air entry with minimal wheezing on both sides.  The patient is not able to follow instructions to use the peak flow meter.  Which of the following is the most important next step in management?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c075_0e77_8f63_897e582da143_MD0005_00 Response to therapy should be assessed periodically during the first few hours of treatment of an asthma exacerbation. Failure to recognize early signs of clinical deterioration and impending respiratory failure are responsible for the majority of morbidity and mortality seen in status asthmaticus. Clues to clinical deterioration include: Accessory muscle use with suprasternal retractions Cyanosis Diaphoresis Exhaustion or extreme fatigue Marked tachycardia Pulsus paradoxus PaCO₂ >42 mm Hg Peak expiratory flow (PEF) <25% of baseline These patients should be assessed immediately for impending respiratory failure. Ventilatory support should be considered early in the course of the disease. Signs of impending respiratory failure include: Confusion and drowsiness Depressed respiratory drive Severe hypoxemia Patients exhibiting any of these symptoms should be intubated immediately to secure and protect the airways. (Choices A, B, and C) Aggressive treatment with inhaled beta-2 agonists, inhaled ipratropium, and intravenous corticosteroids is the initial step in management of acute severe asthma exacerbation (PEF <40%). This patient also qualifies for intravenous magnesium as he has failed conventional therapy. However, with impending respiratory failure, immediate endotracheal intubation and mechanical ventilation should be performed as a priority without waiting for further medical therapy or admission to the hospital. (Choice E) Intravenous theophylline provides no effective bronchodilation in acute asthma exacerbation. Educational objective: Signs and symptoms of impending respiratory failure and status asthmaticus should be recognized early in asthma exacerbation. These patients should be intubated immediately to secure the airways. Inhaled beta agonists, inhaled ipratropium, intravenous glucocorticoids, and intravenous magnesium should also be given. References: Management of acute asthma in adults in the emergency department: assisted ventilation. (http://www.ncbi.nlm.nih.gov/pubmed/19901044)

A 27-Year-Old Man Comes to the Emergency Department with Sudden