MEDizzy - A 29-year-old male with a history of asthma presents to the

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A 29-year-old male with a history of asthma presents to the ED with severe SOB for the past 2 days. He also complains of sore throat, generalized malaise, and a nonproductive cough. He denies chest pain, fever, and chills. Temperature = 98.9°F, HR = 95, RR = 33, BP = 140/82, and O2 saturation = 90% on room air. Breathing is labored, and he is speaking in short gasps. Lung auscultation reveals bilateral diffuse expiratory wheezing. There is no urticaria or angioedema on skin examination. ABG is drawn: 7.42/43/70/22. What is the appropriate next step in managing this patient?

ExplanationNebulized albuterol for bronchodilation. This patient is likely suffering from an asthma exacerbation caused in part by his recent exposure to a viral illness. There were wheezes on examination with no urticaria or angioedema, making an anaphylactic reaction unlikely. (C) Management of an acute asthma exacerbation involves oxygen administration as well as intermittent or continuous nebulized albuterol, which is the first-line treatment. If the patient fails to respond to albuterol, then ipratropium and magnesium are additional options to promote bronchodilation. Oral corticosteroids should also be given to reduce airway inflammation during and after the exacerbation. Response to therapy can be monitored by following the SaO2 as well as either the FEV1 or the peak expiratory flow (PEF). Arterial blood gases may also be useful; be concerned about the finding of a normal PaCO2 , which is often indicative of respiratory fatigue leading to the requirement of intubation (hypoxemia should cause hyperventilation and hypocapnia). (A) Oxygen should be administered to asthmatics with a target SaO2 >90%. In COPD, the target is 90% to 94% due to the concern for the development of hypercapnia, however this is not seen in asthma. (B) This patient is unlikely to have pneumonia given that he is afebrile and has no suggestive findings of pneumonia on lung examination. (C) Subcutaneous epinephrine is useful in anaphylaxis, but has no benefit over inhaled β2 -agonists in asthma for bronchodilation. (D) Ipratropium is an anticholinergic and is the first-line treatment for COPD exacerbation (although albuterol is often used too); it may be used as an adjunctive therapy in asthma exacerbation, but albuterol is the first-line therapy.