Tough Question for Smart Person

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What is Next Step in Management?

  • A. Intubate and start mechanical ventilation

    Votes: 91 81.3%
  • B. Administer additional dose of intravenous 125-mg Solumedrol

    Votes: 5 4.5%
  • C. Start antibiotics (Zithromax and Ceftriaxone)

    Votes: 5 4.5%
  • D. Add nebulized Atrovent to the Albuterol

    Votes: 11 9.8%

  • Total voters
    112

Tedebear

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Question from Qbank.

A 27-year-old female with a history of asthma comes to the emergency department (ED) complaining of increasing shortness of air over the last 6
hours. She has been using her Albuterol metered-dose inhaler every hour, without relief of symptoms. In the ED, she has continued to receive continuous Albuterol mini-nebulizer treatments. She also received 125-mg of
intravenous Solumedrol. On physical examination, the patient is using accessory muscles of respiration to breathe. Her blood pressure is 132/82
mm Hg, respiratory rate is 36/minute, pulse is 120, and temperature is 98.6
°F. Peak flow is 140 mL/minute. Pulsus paradoxus is 18 mm Hg. Lung
exam reveals wheezes throughout all fields. Heart exam reveals tachycardia
with no murmurs. Chest x-ray shows no infiltrates. The patient is on 60%
oxygen by face mask and arterial blood gas studies reveals: pH 7.3, PaCO2 48
mm Hg, and PaO2 140 mm Hg. Of the following, what is the next step in the appropriate management of this patient?
 
To me, the most worrisome things are her lack of response to inhaled and IV bronchodilators, her use of accessory muscles, low peak flow, and her blood gas. So in my opinion, if she doesn't get assitance in ventilation now, she'll need it in the very near future. I don't think this is a resp infxn so I wouldn't give Abx. I don't think that given additional beta-agonist will help. Giving ipratropium bromide also would not do much, and would take longer for an effect.
 
Retaining CO2 is bad in asthma. Most often, they should be slightly alkalotic, if anything, and their CO2 is low as they work hard to move air. The fact this person's C02 is high, and now becoming acidotic, despite aggressive therapy, is indicative they are tiring. Intubation seems the most likely answer.
 
This patient is in classic respiratory distress. Assume that she is not on 60% O2, and her Po2 would be around 40-50, which is cause for intubation. The fact that the patient is not showing an O2 tension of 250+, which would be expected in a normally ventilated system (with supplemental O2 of 60%) is cause for concern. SaO2 will likely be normal, and this can be misleading.



addendum: from JCAAI - "Absolute indications for mechanical ventilation have not been delineated. A Pa CO 2 greater than 50 to 60 torr, although serious, is not an absolute indication. Generally indications would include (1) severe agitation requiring sedation to permit administration of therapy; (2) mental obtundation and/or coma; (3) hypoventilation with reduction in tidal volume; (4) sudden or progressively rising Pa CO 2 and falling pH; (5) progressive clinical deterioration with obvious fatigue, usually accompanied by a rising Pa CO 2 and falling pH; and (6) cardiopulmonary arrest. 24 Intubation may be difficult and, if possible, should be done by an individual skilled in intubation. The size of the endotracheal tube depends on the age of the patient; when possible, nasal is preferable to oral intubation. Sedation and neuromuscular blockade (pancuronium) may be necessary to mechanically ventilate these patients. High peak airway pressures should be avoided if possible because barotrauma is increased in this setting."
 
Tedebear said:
Question from Qbank.

A 27-year-old female with a history of asthma comes to the emergency department (ED) complaining of increasing shortness of air over the last 6
hours. She has been using her Albuterol metered-dose inhaler every hour, without relief of symptoms. In the ED, she has continued to receive continuous Albuterol mini-nebulizer treatments. She also received 125-mg of
intravenous Solumedrol. On physical examination, the patient is using accessory muscles of respiration to breathe. Her blood pressure is 132/82
mm Hg, respiratory rate is 36/minute, pulse is 120, and temperature is 98.6
°F. Peak flow is 140 mL/minute. Pulsus paradoxus is 18 mm Hg. Lung
exam reveals wheezes throughout all fields. Heart exam reveals tachycardia
with no murmurs. Chest x-ray shows no infiltrates. The patient is on 60%
oxygen by face mask and arterial blood gas studies reveals: pH 7.3, PaCO2 48
mm Hg, and PaO2 140 mm Hg. Of the following, what is the next step in the appropriate management of this patient?


This looks strangely familiar....

I would say...Tedebear...that this young woman has just purchased herself a tube.
 
The patients RR is 36. The peak flow is 140. In the average person it should be around 500. The steroids will not kick in for hours. The inhaled albuterol is not working.

I suggest intubation. After that you can give one more dose in steroids. This is for the long term.

You could also try xoponex (think that's how it's spelled). It sometimes works faster than albuterol.

This patient is crashing and need immediate intervention. You don't want to wait too long.
 
For those who put antibiotics.

There is not evidence that the patients has an infection. Even is she did, the antibiotics will not work in the next 5 minutes.

Atrovent and albuterol has not been shown to work better.

Steroids do not work on acute patients. It takes about 6 hours for them to start to work.

if you reason the answer out in this fashion. the answer would have come easier. The trick part is the atrovent and albuterol.
 
its a tad concerning that in the Emergency medicine forum about 25% or more guessed for Atrovent/Albuterol. The General Forum did much better, surprising since I bet the majority won't ever have to deal with asthma exacerbations, whereas ED docs most assuredly will. (or have)
 
I follow the old mantra: "The thought process of CONSIDERING intubation is an indication to intubate." Along with all the other reasons everyone else said. Intubate.
 
Strength&Speed said:
its a tad concerning that in the Emergency medicine forum about 25% or more guessed for Atrovent/Albuterol. The General Forum did much better, surprising since I bet the majority won't ever have to deal with asthma exacerbations, whereas ED docs most assuredly will. (or have)

Let me try to explain the reasoning behind this. Although a rising PCO2 and falling pH is VERY concernig in this asthmatic, intubating an asthmatic in the throws of a severe attack is not without significant risks such as barotrauma.

As an emergency medicine resident, you're correct, I see asthma exacerbations almost every day. The goal is to reverse the obstruction (bronchospasm + inflamation) thus restoring proper ventilation. Although sedating and intubating this patient will help to ventilate her it is not the end of your work, and it's not as simple as this question would suggest. You are obliged to throw everything at this patient prior to resorting to intubation.

It takes only a couple of minutes to intubate a patient. Her pH and PCO2 are not at critical levels....yet. We have time to work. Combivent (albuterol/atrovent) continuous updraft, Steroids, Heliox, Magnesium (mixed data in the literature but I've seen 2gm of Mag work dozens of times), Sub Q epi is a choice in this young woman, Sub Q terbutaline, time, time time.

Don't treat numbers, treat the patient. Is she mentating? Is she drowsy? Is she agitated? Despite what the test question would suggest, if you rush to intubate her before using ALL available therapies, before truely indicated and you drop her lung on the vent, you would, unequivically, be WRONG.

I have had patients with much more concerning ABG's, tachypneic into the 40's, and have held off on the tube (granted, the ET tube was at the bedside and the laryngoscope in my pocket) long enough for them to turn around on their own, saving them an ICU admission, possible pneumothorax (not an uncommon complication when you intubate this pt population), and all the other complications that go along with mechanical ventilation.

Yes, yes, yes......the text book answer is mechanical ventilation in this VERY classic example of an asthmatic with a pH>40. However, this is why there is "art" in the practice of medicine.
 
In an asthmatic patient, the first objective response is hyperventilation secondary to the stimulation of the lining of the airways from the inflammatory mediators and from the bronchospasm. This leads to increase in pH and fall in pCO2. She has been hyperventilating for the last 6 hours and she had not showed any improvement with b2 agonist therapy. Ipratropium will NOT make a significant difference. She is showing signs of fatigue. Her pH has dropped mainly due to lactic acidosis, rather than from the increase in pCO2. So she has a mixed metabolic and respiratory acidosis. Soon she will start decompensating.
Here we need to releive her fatigue and stop the progression of lactic acidosis. Simultaneously, we need to act on the bronchospasm.
So, we start with intubation and give her some epinephrine and IV steroids.
I agree we should treat the patient and not the numbers, but these numbers are giving you a prior warning and as professionals we have to look at everything. These tests are there for a meaning and they give us the insight into the patient's pathophysiology.
Mechanical ventialtion can lead to barotrauma. We got to be careful. Everyday when we drive on the freeway, there is a good chance we might crash and die, however, we make sure we drive safely.
The idea is to see the underlying pathophysiology and individulize it. Thanks. Please do critique on my management.
 
gpops said:
Let me try to explain the reasoning behind this. Although a rising PCO2 and falling pH is VERY concernig in this asthmatic, intubating an asthmatic in the throws of a severe attack is not without significant risks such as barotrauma.

As an emergency medicine resident, you're correct, I see asthma exacerbations almost every day. The goal is to reverse the obstruction (bronchospasm + inflamation) thus restoring proper ventilation. Although sedating and intubating this patient will help to ventilate her it is not the end of your work, and it's not as simple as this question would suggest. You are obliged to throw everything at this patient prior to resorting to intubation.

It takes only a couple of minutes to intubate a patient. Her pH and PCO2 are not at critical levels....yet. We have time to work. Combivent (albuterol/atrovent) continuous updraft, Steroids, Heliox, Magnesium (mixed data in the literature but I've seen 2gm of Mag work dozens of times), Sub Q epi is a choice in this young woman, Sub Q terbutaline, time, time time.

Don't treat numbers, treat the patient. Is she mentating? Is she drowsy? Is she agitated? Despite what the test question would suggest, if you rush to intubate her before using ALL available therapies, before truely indicated and you drop her lung on the vent, you would, unequivically, be WRONG.

I have had patients with much more concerning ABG's, tachypneic into the 40's, and have held off on the tube (granted, the ET tube was at the bedside and the laryngoscope in my pocket) long enough for them to turn around on their own, saving them an ICU admission, possible pneumothorax (not an uncommon complication when you intubate this pt population), and all the other complications that go along with mechanical ventilation.

Yes, yes, yes......the text book answer is mechanical ventilation in this VERY classic example of an asthmatic with a pH>40. However, this is why there is "art" in the practice of medicine.

I don't think anyone can fault you for intubating this patient given this information. But you almost definitely will be faulted if this patient goes apneic because you didn't intubate early enough.

This is where the art of medicine really kicks in... how far can you push the envelope in holding off intubation in lieu of other therapies.
 
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