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Question: Asthma

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8yo girl with history of asthma presents with increased work of breathing x 1 day. She is alert but anxious appearing, tachypneic, has retractions and flaring, and her O2 sat is 88% on room air. She has poor air movement and few wheezes are heard. She is given two 5mg albuterol nebulized treatments and oral steroids. An initial venous blood gas had a pH of 7.45 and pCO2 of 34. A repeat blood gas shows a pH of 7.33 and pCO2 48, O2 sat on oxygen with 3rdnebulized albuterol is 91%; her mental status is unchanged

What is your best next step?

pemsou5_wp • July 24, 2018

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  1. Kelly July 24, 2018 - 8:30 am Reply

    A) Give additional medical management for asthma exacerbation
    The patient’s respiratory status is worsening, but she is still maintaining her mental status and oxygenation with O2 supplementation. Medical management has not yet been maximized – she can receive nebulized ipratroprium and IV magnesium. Intubation of asthmatics should be a last choice only when respiratory failure is imminent as complications such as breath stacking and barotrauma are common, and mechanical ventilation of asthmatic patients is fraught with challenges. Non-invasive ventilation strategies may be tried instead if the patient is not yet unstable. The patient should not be sent out of the department as she is worsening. An ABG is unlikely to provide additional useful information and will only distress her more. Respiratory depressants should not be given.

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