A 32-year-old woman comes to the emergency department with progressive difficulty breathing over the past few days. The patient has nasal congestion, dry cough, and wheezing but no fever, chills, recent travel, or sick contacts. Medical history is significant for eczema and a family history of asthma. Temperature is 37 C (98.6 F), blood pressure is 138/78 mm Hg, pulse is 114/min, and respirations are 28/min. Oxygen saturation is 95% on room air. Nasal congestion is noted on examination. The ears and throat are normal, and heart sounds are normal without murmurs. The patient has mild scattered wheezing but does not appear to be in respiratory distress. Chest x-ray is shown in the exhibit. Which of the following is the most appropriate pharmacotherapy for this patient?

Question

A 32-year-old woman comes to the emergency department with progressive difficulty breathing over the past few days.  The patient has nasal congestion, dry cough, and wheezing but no fever, chills, recent travel, or sick contacts.  Medical history is significant for eczema and a family history of asthma.  Temperature is 37 C (98.6 F), blood pressure is 138/78 mm Hg, pulse is 114/min, and respirations are 28/min.  Oxygen saturation is 95% on room air.  Nasal congestion is noted on examination.  The ears and throat are normal, and heart sounds are normal without murmurs.  The patient has mild scattered wheezing but does not appear to be in respiratory distress.  Chest x-ray is shown in the exhibit.  Which of the following is the most appropriate pharmacotherapy for this patient?

Quizplus · Accepted Answer

11ec25c8_d1f0_0de0_bc81_11b96f3c77fa_MD0003_00 This patient's cough, wheezing, and difficulty breathing are likely caused by an exacerbation of new-onset asthma. Although asthma most commonly begins in early childhood, it can remain undiagnosed and become symptomatic in adulthood. A personal history of eczema and family history of asthma are risk factors. Asthma is characterized by airway hyperreactivity and inflammation and may be exacerbated by an upper respiratory tract infection, allergies, environmental irritants, or exercise; some cases have no identifiable trigger. Presentation typically includes cough, wheezing, chest tightness, and shortness of breath. Ordering a chest x-ray is appropriate in this patient with respiratory symptoms and no asthma history, but it is not typically required in patients with a classic exacerbation because it is often unrevealing. X-ray findings may be normal, as in this case, or show lung hyperinflation due to chronic air trapping. lung hyperinflation First-line treatment for an asthma exacerbation is albuterol, an inhaled short-acting beta agonist that relaxes airway smooth muscle, causing bronchodilation. In patients with significant respiratory distress (eg, accessory muscle use), ipratropium (inhaled anticholinergic) may be used in conjunction with albuterol in the acute setting for additional bronchodilation. A systemic glucocorticoid (eg, prednisone, dexamethasone) should also be administered for an acute asthma exacerbation to treat underlying inflammation that contributes to bronchiolar narrowing and obstruction. (Choices A and C) Antibiotics are not indicated for asthma exacerbations, which are commonly triggered by viral infections, unless the course is complicated by bacterial pneumonia (eg, infitrate on x-ray). This afebrile patient without evidence of pneumonia on chest x-ray does not require antibiotics. (Choices D and E) Ipratropium is not as effective as albuterol for the treatment of asthma and should be used only during moderate-to-severe exacerbations as an adjunct to beta agonist therapy. Educational objective: New-onset asthma can present as an acute exacerbation with cough, wheezing, and shortness of breath. Treatment includes albuterol (inhaled short-acting beta agonist) for bronchodilation and a systemic glucocorticoid (eg, prednisone) to reduce airway inflammation. References: Asthma exacerbations: pathogenesis, prevention, and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/28689842) Efficacy and safety of ipratropium bromide/albuterol compared with albuterol in patients with moderate-to-severe asthma: a randomized controlled trial. (http://www.ncbi.nlm.nih.gov/pubmed/27130202)

A 32-Year-Old Woman Comes to the Emergency Department with Progressive