Asthma ‘Matthew C. Tews, DO Key Points + Patients with severe asthme exaceibations may have such severe restriction of aifiow that they do nat exhibit wheezing on examination. Beta? agonists are the mainstay of treatment for acute asthma exacerbations Comtiasteods should be ven to patients who do not respond intl to beta? agonists and in these with moderate to severe exacerbations. INTRODUCTION Asthmais a chronic disorder ofthe airways thatis astociated with infammation, bronchial hyperreactivity, and intermit- tent airflow obstruction. The most common chron disease in childhood, itis also common in the adult population. Presentations of acuteasthma account for more than 2 mil~ lion emergency department (ED) visits annually. The causes are mulifactoria, but the pathophysiology is characterized by the release of inflammatory cell mediators that lead 10 airway smooth muscle constriction, pulmonary vasculature leakage, and mucous gland secretion. ‘Asthma is characteriaed by progressive shortness of breath, variable airflow obstruction, and wheezing Symp- toms fluctuate over time, and patients with worsening, symptoms due to a trigger are considered to havean “exac~ erbation” and require prompt treatment to reverse the airflow obstruction. CLINICAL PRESENTATION ‘An acute asthma presentation is due to a decrease in expi- ratory airflow and is characterized by progressive symp- ‘toms of shortness of breath, a nonproductive cough, and. 89 ‘+ Peak expiratory flow rate and forced expiratory volume in 1 second are objective measures ofthe severity of a patient's asthma exacerbation and should be followed sesally to measure improvement. ‘wheezing inal ung feds. Symptoms may develop over a period of hours, days or weeks, but often there is an acute worsening that prompts the patient to sek medical care. ‘The most common trigger of acute asthma is an upper respiratory tact infection, but other factors may lead to sudden worsening of symptoms (Table 21-1). D> History Obtaining a thorough history may not be possible in an acute asthma exacerbation. A focused history should be ‘obtained in parallel with initiation of therapy to reverse Table 21-1. Acute asthma triggers. ‘ewronmental alergers| = ‘Gastoesophageal fluc disease bac sme ‘Dccupatonel exposues ‘nhl initants ‘Stessindued Envronmental changes (weather) Ai pollutantsCHAPTER 21 Table 21-2. Risk factors for mortality in asthma. Chon stead wage Steanstesofshot acing bet agents per onth History of intensive cae wit admissions ‘Previous intubations fo asthma ‘Cainguimonary comorbidities ar uy use law secineconomic status er imercityresdence airflow obstruction, regardless of the trigger. Once the patient has improved and is able to provide more history, aan attempt should be made to characterize the triggering event, rapidity of symptom onset, and the severity of the exacerbation, which will help guide further treatment and disposition. Characterization of the severity of the patient’s underlying asthma may help predict mortality (Table 21-2). ‘Attempting to define the patients underlying long- ‘termasthma control does not aid in the management of an acute exacerbation, but will be important to understand when prescribing outpatient therapeutic regimen and ‘follow-up. Patients should be asked about the frequency and duration oftheir current asthma symptoms and recent Deta-agonist usage. Numerous medical conditions can present in a similar fashion to asthma, including pulmonary embolism (PE), ‘pneumonia, congestive heart failure (CHE), acute myocar- dial infarction (AMD, or chronic obstructive pulmonary disease (COPD). The initial history should focus on dif- ferentiating asthma from other life-threatening causes of shortness of breath and wheezing. D> Physical Examination Patients may present with a wide spectrum of severity, from an inerease in coughing to obvious respiratory dis- tress with tachypnea and accessory muscle use. Mental status should be assessed initially ecause alterations in consciousness may affect the patient's ability to protect their airway. A diminished level of consciousness is an indicator of impending respiratory arrest. The neck should be palpated for tracheal deviation and crepitus, as might occur with spontaneous pacumothorex. The lung, exam is variable and demonstrates prolonged expiration with wheezing. However, the severity of the airflow obstruction cannot be gauged by the loudness of the wheezing. The patient who is audibly wheezing may still have good air movement on auscultation, whereas the Auiet sounding chest with little ait movement isa sign of severe disease because there is not enough airflow to pro- duce a wheeze. Percussion of the thorax reveals hyper- resonance due to ait trapping, Evaluation of extremity cedeme will help differentiate asthma from other causes of difficulty breathing, DIAGNOSTIC STUDIES ‘The use of diagnostic studies is limited in the evaluation of | 4 patient with an asthma exacerbation. However, certain diagnostic modalities may be indicated, depending on the clinical situation. p> Laboratory ‘An arterial blood gas (ABG) may demonstrate an increased CO, level, indicating ventilatory failure and need for admision to the intensive care nit (ICU). However, the patients clinical condition is more important than an ABG to predict outcome or the need for intubation, Electrolytes and rena function may be helpfili the paint as comor- bidities that make metabolic derangements more ily. An levated white blood cll count may ai in the diagnos of ‘concomitant pulmonary infection. > Imaging Hyperinflation ofthe lungs is seen in moderate to severe -exacerbationsand may be reflected on the chest x-ray (CXR) ‘3 an increased anteror-posterior diameter and flattering ‘of the disphragm muscles ACXR should be considered in patients not responding to treatment, those with fevers {and those requiring hospitalization or intubation, About 15% ofthese patents have unsuspected pneumonia, CHE ‘pneumothorax, or peumomediastinam. > Electrocardiogram ‘The electrocardiogram (ECG) is not routinely useful and ofien demonstrates sinus tachycardia. In severe asthma ‘exacerbations, a right ventricular strain pattern that nor- malizes with improvement of airflow may be seen, Dysrhythmias and ischemia may occur in older patients with coexistent heart disease, PROCEDURES > Peak Expiratory Flow Rate Forced expiratory volume in I second (FEV 1) and peak expi- ratory flow rate (PEFR) are objective measurements of the degree of airway obstruction that can be performed at the bedside (Figures 21-1 and 21-2). These aid the physician ‘monitoring the progression of treatment and determination ‘of patient disposition. Predicted values for FEVI and PEFR. ‘are based on the patients age, sex, and height and compared ‘with a standardized chart or by using the percent of the patients personal best peak ow. PEFRs <25% predicted indicate a life-threatening exacerbation and require aggressive ‘management. The severity of asthma can be determined by the percentage PEFR and categorized as mild (>7096), moder ‘ate (40-G97), or severe (<40%6) and will suide further ther~ ‘apy.PEER values at | hour fiom presentation and beyond are useful to determine nced for hospitalization, Either FEVI ot PEFR can be used in acite exacerbations,ASTHMA Fev meter, The components of nebulizer treatment include the mouthpiece, medication reservoir, O, tubing, and “accor dion’ extension tube. The albuterol is placed within the reservoir, and the components are fastened together. The entension tube provides a reservoir of “trapped” O, and nebulized albuterol that can be inhaled with each breath. The O, tubing ishooked up to the green wall O, port and. tured to 6 L/min because the yellow wall pot only deiv- cs air (21% FiO, . The patient holds the nebulizer during the treatment (Figuze 21-3). IF the patients unable to hold thetreatment, «facemask is used instead. The diagnosis of an asthma exacerbation in the ED is relatively straightforward. Any patient who has a history of asthma and presents with wheezing, cough, and dys- pea likely has asthma as the underlying cause. However, there are several situations in which wheezing may not be asthma. Anaphylaxis may present with wheezing, but the patient will often have urticaria and sometimes gastroin- testinal symptoms. CHF may present with “cardiac wheezing,” but the patient will often have “wet” lungs sounds with rales in the bases, an enlarged heart on CXR, peripheral edema, and jugular venous distention. CHE Peak flow meter. can have many underlying causes, but often these indi- Viduals will have underlying heart disease and other comorbidities. The presence of wheezing is common in COPD, but unless the patient has a history of a,-antitrypsin deficiency, this type of presentation is found in patients with smoking history and who are Handheld nebulizer treatment.