A 28-year-old woman comes to the emergency department because of worsening shortness of breath and wheezing for the last 2 days. She denies fever, chills, or chest pain. She has a history of asthma and her symptoms occur mainly during the winter months. She denies nocturnal asthma episodes. She uses an albuterol inhaler intermittently, which usually controls her symptoms very well. However, over the last few hours she has taken several puffs of her inhaler, with no improvement of her current symptoms. She has no other medical problems and takes no other medications. She does not use tobacco or illicit drugs.
Her temperature is 36.7 C (98.1 F), blood pressure is 128/76 mm Hg, pulse is 108/min, and respirations are 20/min. She is in moderate respiratory distress. Lung examination reveals bilateral wheezing and prolonged expiration with use of accessory muscles. Her peak flow is 190 L/min.
She is given continuous nebulized albuterol, a dose of corticosteroids, and is admitted to the hospital. The following day, she has marked improvement of her symptoms and there are no wheezes heard on auscultation. She wants to go home.
Apart from a short acting beta agonist, which of the following is the most appropriate discharge medication for this patient?

Question

A 28-year-old woman comes to the emergency department because of worsening shortness of breath and wheezing for the last 2 days.  She denies fever, chills, or chest pain.  She has a history of asthma and her symptoms occur mainly during the winter months.  She denies nocturnal asthma episodes.  She uses an albuterol inhaler intermittently, which usually controls her symptoms very well.  However, over the last few hours she has taken several puffs of her inhaler, with no improvement of her current symptoms.  She has no other medical problems and takes no other medications.  She does not use tobacco or illicit drugs.
Her temperature is 36.7 C (98.1 F), blood pressure is 128/76 mm Hg, pulse is 108/min, and respirations are 20/min.  She is in moderate respiratory distress.  Lung examination reveals bilateral wheezing and prolonged expiration with use of accessory muscles.  Her peak flow is 190 L/min.
She is given continuous nebulized albuterol, a dose of corticosteroids, and is admitted to the hospital.  The following day, she has marked improvement of her symptoms and there are no wheezes heard on auscultation.  She wants to go home.
Apart from a short acting beta agonist, which of the following is the most appropriate discharge medication for this patient?

Quizplus · Accepted Answer

11ec193a_969b_99cf_853d_e7b1ed5fced7_MD0002_00 This patient had a severe asthma exacerbation, which is defined as a peak flow of < 200 L/min (or < 40% of normal peak flow). Current guidelines recommend systemic corticosteroids for all patients with moderate (< 70% normal peak flow) to severe exacerbations, and oral tablets work as effectively as intravenous corticosteroids in patients without emesis. However, the intravenous route is preferred in patients with respiratory distress or intolerance to oral steroids. Even though this patient previously had only occasional symptoms, one episode of asthma exacerbation severe enough for hospitalization is an indication for maintenance inhaled corticosteroids. Also, all patients should receive a short course of oral steroids to prevent relapse even if they respond dramatically to one day of steroid therapy. The duration of steroid therapy varies with the severity of the attack, but is usually between 3-10 days total for most patients. There is no reason to taper steroids if they are going to be used for less than three weeks, since adrenal axis suppression is uncommon with < 3 weeks of steroid therapy. (Choice C) Nebulized ipratropium is reserved for patients with severe airflow obstruction who fail to improve after short acting bronchodilators. (Choice E) Oral leukotriene antagonists are used in treating chronic asthma, but they do not have a clearly established role in treating acute exacerbations. Educational objective: Inhaled short-acting beta-2 selective adrenergic agonists and systemic corticosteroids are the mainstay for emergency department treatment of an acute asthma attack. Patients should be discharged with a prescription for a short course of oral steroids and an inhaled corticosteroid to prevent recurrent asthma attacks following discontinuation of oral steroids. __________ References: Corticosteroids for preventing relapse following acute exacerbations of asthma (http://www.ncbi.nlm.nih.gov/pubmed/10796506) The effectiveness of inhaled corticosteroids in the emergency department treatment of acute asthma: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/12140492)

A 28-Year-Old Woman Comes to the Emergency Department Because of Worsening