TWITER 1.1

twiter1A 35-year-old woman presents to the resuscitation room with shortness of breath that began earlier in the afternoon.  The patient has a history of asthma.  On exam, she is in obvious respiratory distress with retractions, accessory muscle use, and faint wheezing on auscultation of her thorax.  She rapidly decompensates and has to be endotrachealy intubated.

Acute asthma exacerbation with respiratory faiulure

  • The most common predictors of fatal asthma seem to be a past medical history of intubation/mechanical ventilation and underuse of steroid therapy
  • Findings suggestive of severe asthma
    • dyspnea so severe the patient is only able to speak a few words at a time
    • poor air movement on auscultation of the lungs
    • use of accessory muscles – reflects diaphragmatic fatigue
    • silent chest – indicates that airflow is dramatically reduced and is no longer adequate to cause wheezing
    • diaphoresis
    • cyanosis – late finding, appearing just prior to respiratory arrest
    • altered mental status – may indicate hypercapnia and often reflects impending respiratory failure
  • Treatment of severe asthma
    • beta2-agonists (onset of action < 5 minutes)
    • anticholinergic agents (onset of action up to 30 minutes)
    • corticosteroids (onset is gradual with initial improvement at 3 hours)
    • heliox
    • magnesium sulfate
    • terbutaline/epinephrine – reserved for patients who are too sick to provide an effective respiratory effort
    • mechanical ventilation – high rate of iatrogenic complications (barotrauma)
      • hypoventilate (8-10 breaths per minute – permissive hypercapnia)
      • I to E ratio increased to at least 1:4

TWITTER notes (This Week In The ER) is an educational resource that presents high-yield, case-based information from actual patient presentations in the Detroit Receving ED.

2 Responses

  1. isnt it permissive hypercapnia?

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