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The Patient
Male patient in his 60s
Past Medical History: COPD, asthma, morbid
obesity, hypothyroidism, and depression
Hospitalization
Diagnosis: Acute hypoxic respiratory failure Status
asthmaticus
Intubated in the ED
Transferred to VA from another hospital
Admitted to the ICU: intubated, sedated, and
stable.
Asthma: Pathophysiology
Inhaled antigens activate immunoglobulin E, mast
Asthma: Pathophysiology
Asthma can range from an acute bronchospasm to
airway inflammation, to permanent airway
remodeling.
Hypertrophy of smooth muscle, new vessel
Symptoms
Sensation of chest
Alteration in mental
Cough
Tachycardia
Wheezing
Tachypnea
Prolonged expiration
Pulsus paradoxus
Silent chest
constriction
Paradoxical respiration
status
Status Asthmaticus
Severe asthma attack that does not respond to
Admission to VA Hospital
Intubated and sedated.
Transferred immediately to ICU.
Drips: propofol and fentanyl
Ventilator mode: Assist Control
Clinical Presentation
Respiratory Assessment
Neurology Assessment:
Sedated
Unable to follow commands
PERRLA brisk
pH: 7.45
CO2: 44
O2: 226
HCO3: 24
O2 saturation: 98%
Chest X-ray
Hyperinflation, but no effusions or consolidation.
Nursing Diagnoses
Ineffective Airway Clearance related to
Day 1 Interventions
Continued propofol and fentanyl for continued
sedation.
Expected to improve ventilation and prevent further
ventilator dyssynchrony.
Kept to a RASS of -4 or -5
Solumedrol (methylprednisolone)
Magnesium sulfate
Day 5 Interventions
Small improvement with auto PEEP down to 0 with
epinephrine on a low dose
Day 6
Nimbex and epinephrine drip restarted due to
worsening auto PEEP over night.
Aminophylline
Bronchodilator smooth muscle relaxation
Suppression of airway stimuli
Limited by the drugs narrow therapeutic index
Only a few studies done on the efficacy for treating
acute COPD exacerbations
2 largest studies have contradictory results
Day 7
Respiratory Assessment after initiation of
aminophylline
Lung sounds more clear
More air movement
Decreased wheezing
Day 10
Patient extubated
Venti mask at 55% FiO2
Face mask at 5 liters when on albuterol nebulizer.
Outcomes
Eventually sent to long term care
On room air and CPAP at night
Clear/dim lung sounds
Albuterol nebulizer every 4 hours
Budesonide/formoterol 2 puffs as needed
Discussion
Is there anything more that could have been done
in the outpatient clinic to avoid this severe
asthmatic exacerbation from occurring?
Acknowledgements
Jennifer Sinclair, RN
References
ANDERSON, E., & EMERMAN, C. L. (2000). Managing acute exacerbations of chronic obstructive pulmonary
disease.The Journal of Critical Illness,15(12), 674. Retrieved from
http://go.galegroup.com.ezproxy4.library.arizona.edu/ps/i.do?id=GALE
%7CA76665401&sid=summon&v=2.1&u=uarizona_main&it=r&p=ITOF&sw=w&asid=b2feaddfbda31439c3d
db4c9fbaa4795
Cydulka R.K. (2016). Acute Asthma. In Tintinalli J.E., Stapczynski J, Ma O, Yealy D.M., Meckler G.D., Cline
D.M. (Eds), Tintinallis Emergency Medicine: A Comprehensive Study Guide, 8e. Retrieved July 27, 2016
from http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=1658&Sectionid=109429684