06c ShortnessOfBreath Pt3 V3

By Adem Lewis / in , , /

Hi, I’m Doctor Rebecca
Walker, and today we’ll continue with Part 3 of the
Shortness of Breath case. We started with a
52-year-old female. She had been
wheezing for two days and having trouble breathing. She came to the Emergency
Department hypoxic. She was speaking,
but she started becoming more somnolent. Her past medical history– she
had some breathing problems in the past. She had been exposed
to dust recently when she was cleaning her house. And we positioned here
in an upright position and started her on some
oxygen by face mask. We also put her on a
continuous pulse oximetry. We took a history and found out
that she had a recent exposure to dust from sweeping her house. She had these similar
symptoms previously and on her physical
exam, she had bilateral wheezing in her lungs. She showed accessory
muscle use in her neck and in her chest wall. She had no signs of
fluid overload or edema. So we take a more
detailed history now, now that she’s a
little bit more stable, and find out that, no, she
hasn’t been having any fevers. She has been having a
little bit of cough. No chest pain. No tarry or bloody stools. No vomiting. No weight loss. No hemoptysis. She does have this prior
history of similar symptoms. She denies being a smoker. She dies having
palpitations or syncope. And these are all very
important questions to ask any patient who comes
in with shortness of breath. So when we find out that
these few things come to our attention, we want to
take a little bit closer look on what those mean. So our patient says, yes, she
has had these similar breathing problems in the past. We ask her if she
had wheezing before and if her symptoms seemed very
similar to what she has today. She also tells us
that she has indeed needed nebulizers
and steroids to treat her problem in the past. So we remember the long
differential diagnosis of shortness of breath, and we
really are narrowing it down now that she likely has
the diagnosis of asthma. And so when we find out more
about what asthma is exactly, we look at the airways. And this is the bronchus. And we see here the
smooth muscle dilation, which narrows the
bronchial tubes. You also have
bronchoconstriction that narrows the airway. So the problem is that there’s
not enough space for the air to actually pass through
these air passages. Here, we see an increase
in mucus production, which is also a problem
with asthmatics. Often the mucus has to
be cleared by coughing, and so that’s why
coughing is often associated with
asthma exacerbation. So thinking about what
we saw on the video, we see here that an
asthmatic bronchial has a much narrower
passage for the air to go through than
a normal bronchial. The air goes faster,
and that’s what causes the high-pitched sound of
wheezing that we heard earlier in our patient. And two of the mainstays of
treatment for asthma and asthma exacerbation are
steroids and nebulizers, so what we call
beta2 agonists, which help to dilate the smooth muscle
and open the patient’s airway. Steroids take a little longer
to work than the nebulizers. The nebulizers actually
work within minutes. So when we mentioned
steroids, prednisone is a good choice– 60
milligrams PO dose for adults. If the patient is unable
to tolerate PO medications, we can give IV
methylprednisolone, or Solu-Medrol, 125 milligrams. And this, again,
suppresses the inflammation that we saw earlier
in the airway. Beta-2 agonists– albuterol,
salbutamol– this causes the smooth muscle to relax
and just dilates the bronchial passages that we saw there. 2.5 to 5 milligrams
every 20 minutes, and you can give repeated doses. In fact, if the patient has
a very severe exacerbation of asthma, we
should consider just starting them on a continuous
neb for asthma exacerbation when they come to the
emergency department. In a crashing
asthmatic– so someone that you’re really
worried about and someone who looks like they
need to be intubated– we really want to try to avoid
intubation if at all possible. And so, we would give that
patient 2 grams of magnesium IV and also consider subcutaneous
or an terbutaline drip or an epinephrine drip. Patients can have
allergic triggers that might start an
asthma exacerbation. Sometimes, it’s an
allergy or exposure to dust, as in our patient. Cigarette smoke or viral
infection of the lung or chest can also trigger an
asthma exacerbation. Pollen or other environmental
allergens as well as animal fur can trigger an
asthma exacerbation. Our patient had been
sweeping her house and was exposed to dust. So this is a common
reason that someone has an asthma
exacerbation– is that it was a trigger from
something else. High-risk asthma patients
are important to identify. So if the patient that
you are seeing in the ER is at high-risk, meaning
that they have previously had asthma that was
uncontrolled as an outpatient, maybe they’re increasing the
usage of an albuterol inhaler, if they’ve been intubated
or hospitalized in the past, if they have
worsening symptoms– these are important things
to identify in the patient that you’re seeing in
the emergency department, because this is someone that
you might consider admitting to the hospital versus sending
home given that they’re high-risk for
deterioration later. Diagnostic testing in asthma is
often not actually necessary. If you are considering
another diagnosis, then it’s a good idea to get
an EKG for any heart problems. A chest x-ray is also
not generally needed just for an asthma exacerbation. If you did get a chest
x-ray in an asthma patient, it would likely look like this
one, which is hyperinflated. We see here the full lung
fields, and some of that is due to air trapping
and difficulty in the patient exhaling
all the air that’s been trapped in their alveoli. The lab tests are
also something that actually have a pretty
limited use in asthma. But if you’re considering
a patient with shortness of breath and you’re not
sure of the diagnosis, then they can be useful. We would get cardiac
markers if we think that there’s a chance for
any cardiac cause or ischemia. Electrolytes can show
if the patient has an anion gap or
acidosis or dehydration or other electrolyte
abnormalities. Leukocytosis can point
towards a possible infection. And hemoglobin can
give you the answer if the patient is
very anemic and that’s the cause for the
shortness of breath. In asthma, none of these
laboratory examples are totally necessary,
but they can be helpful in ruling
out other things. So let’s take a
look at our patient. And we see here that
her oxygen saturation has very much improved. It’s 97%. She’s sitting up and she’s
looking a lot more comfortable. However, she’s still
on a face-mask oxygen and requiring that oxygen to
maintain her saturation at 97%. So this is a patient
that definitely needs to come into the hospital
and have continued oxygen supplementation and
reassessment, because she is at high-risk for doing worse at
home given that she’s requiring oxygen in the ER. So in summary, we want to
give every patient with asthma some key interventions that
can really be lifesaving. Asthma is a very common
condition and a frequent reason for patients to present to
the emergency department with shortness of breath. So we want to treat every
acute asthma exacerbation with albuterol beta-2
agonists and steroids to decrease inflammation. If the patient has
very severe asthma, we really want to try and
avoid intubation if possible. And so, we would consider giving
magnesium 2 grams IV as well as a terbutaline epinephrine,
either subcutaneously or a drip. And we want to
consider admitting to the hospital any
high-risk asthma patients– so patients who have been
previously hospitalized or intubated, and
as well, patients who are requiring oxygen,
of course, in the ER. So they can’t have oxygen
at home– most of them– so this is someone who
would automatically be put in the
high-risk category. Thank you so much
for your attention, and this concludes the
Shortness of Breath case. Thanks.

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