# Acute Asthma Exacerbation
-- ABCs: does the patient need to be intubated? concerning features include RR>30, HR >120, pulse Ox <90%, hypercapnia, accessory muscle use, inability to speak in full sentences, AMS, silent chest
-- Chart Check: PFTs, home regimen, fill histroy, prior exacerbations and intubations
-- Admission Criteria: unable to control with usual home regimen
-- HPI Intake: timing, rescue inhaler use, night-time awakenings, access to meds, new meds, sick contacts, prior exacerbations/intubations
-- Can't Miss: hypercarbia, tiring out, need for intubation
-- Admission Orders: *** CBC, BMP, CXR, VBG, consider RVP
-- Initial Treatment to Consider: *** If severe with impending respiratory failure, duonebs q20, methylpred IV 60-125mg, Magnesium IV 2g q20 minutes, and transfer to the ICU; If in ICU, methylpred 125mg IV q6, Mg IV 2g q20 minutes, continuous albuterol nebs, consider BIPAP trial if desperate to avoid intubation (not great data that this helps)
-- History: *** timing, rescue inhaler use, access, new meds, sick contacts; PFTs, home regimen, prior exacerbations and intubations, code status,
-- Clinical: *** fevers, URI sxs, cough,
-- Exam: *** general appearance, WOB, wheezing, cough, AMS
-- Data: *** PEF, CXR, WBC, RVP, VBG/ABG
-- Etiology/DDx: *** infections, exercise, cold, smoke, allergens, drugs (ASA, NSAID, BB)
The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.
-- f/u CBC, BMP, RVP, CXR
-- Monitoring: VBG q ***
-- O2: currently ***, continuous pulse ox with goal >90%
-- Bronchodilators: duonebs q ***; albuterol alone once improving; stack them 3x (q20 minutes) per hour if concern for impending respiratory failure
- Steroids: prednisone 40mg daily vs. methylpred IV 60-125mg for 5-7 days
-- Consider Magnesium 2g, q20 nebs
-- Consider IVF for insensible losses ***
-- Teaching: inhaler technique, trigger avoidance, symptom recognition, care plan
PDF coming soon!
When patients present with an acute asthma exacerbation the standard of care is duonebs, steroids, and O2. Be fearful of a blood gas not suggesting respiratory alkalosis from tachypnea (would see low pH or rising PCO2 - implies worse retaining and that the patient is tiring out). Check on their home regimen - ICS-LABA is the mainstay of outpatient management, and you can update the regimen for patients who have not been seen in the outpatinet setting in some time and are still prescribed just albuterol rescue inhaler. It's okay to to diagnose people clinically with asthma, but being diagnosed as an adult is very rare.