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April 2015: Respiratory

37-year-old female dynamic positioning officer presents to the sick bay with a complaint of continuing shortness of breath and dyspnea on exertion. Symptoms have been progressively worsening over the last two days and she first noticed it when she was walking up a flight of stairs from the helideck on a cold (42°F) and windy day. Symptoms worsened while she was jogging on a treadmill while she was off tour. She also complains about an increase itching of her skin. She is on day 3 of a 14 day hitch.

On review of systems he denies cough, chest pain, headache, fever, chills, joint or muscle pains.

  • Past History: Childhood asthma, eczema, allergic rhinitis
  • Past Surgical History: Breast augmentation (1994)
  • Current Medications: Loratidine (Claritin) 10mg/day, pimecrolimus (Elidel) 1% topical cream as needed
  • Allergies: Bell peppers
  • Immunization Status: Tetanus and influenza are up to date
  • Social History: Drinks alcohol socially, denies illicit drugs & tobacco
  • Family History: Mother with lupus; father with prostate cancer

Vitals

  • Temp 99.2
  • Pulse 79
  • Respirations 22
  • Blood pressure 131/79
  • Pulse Ox 95% RA

Physical Exam

  • General: Alert and Oriented x 4, no acute distress
  • Cardio: regular rhythm and rate, no murmurs appreciated
  • Lung: tachypneic; poor air movement with inspiratory wheezing and prolonged exhalation; no crackles appreciated
  • Abdomen: soft non-tender, non-distended, normal bowel sounds
  • Extremities: no clubbing, cyanosis or edema
  • Skin: few small patches of thickened dry skin over the antecubital fossae consistent with eczema

 

How would you approach this patient?

Diagnosis: Acute Asthma Exacerbation

Treatment

  • Symptomatic control of shortness of breath with a nebulizer treatment
    • Option 1: albuterol sulfate 2.5 mg/3ml sol or levalbuterol inhaled 1.25 mg/3 ml (Xopenex) every 4 hours
    • Option 2: Option 1 + ipratropium bromide 500 mcg/2.5 ml sol every 4 hours
    • Consider supplemental O2 via nasal cannula
    • Betamethasone sodium phosphate/betamethasone acetate (Celestone Soluspan) 6-9 mg IM once
    • Oral steroids such as prednisone 50 mg by mouth daily for 5-7 days or methylprednisolone sodium succinate (Solu-Medrol dose pack) as directed
    • Perform peak flows before and after nebulizer treatments

Discussion

Should the patient not respond to the nebulizer therapy based on the peak flow measurement or through their clinical response, the treatment may be repeated immediately. Once the patient does begin to respond, the treatment can be repeated as needed every four hours. Treatment with the nebulizer may not be necessary as the portable albuterol inhaler can be used 2 puffs every 4 hours for shortness of breath and/or wheezing. Treatment may need to be continued for several days and the patient should be monitored very carefully for improved progress.

Infectious etiologies include viruses (common cold) or bacterial infections (pneumonia or bronchitis), which can cause exacerbations. Treatment of the underlining problem should help relieve the symptoms.  In the case of bacterial infections, macrolide antibiotics such as azithromycin or clarithromycin may provide additional anti-inflammatory benefit.

There are many triggers for an asthma exacerbation, and you should try to determine your patient’s triggers to minimize future episodes. In order to assess your patient’s triggers you should ask the patients questions such as

  • Do you have symptoms year round or certain times of year?
  • Do you have contact with fumes from cleaning agents, sprays, or other chemicals?
  • What substances are used at the work site and do you have co-workers with similar symptoms?
  • Are there any foods/medications that may cause you to have difficulty breathing?
  • Do you have a history of allergic rhinitis?
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