Asthma
Presentation:
A four-year-old male, S.T., presents to the emergency department in acute respiratory distress. He is hunched over in his mother’s lap and is breathing 52 times a minute with a prolonged expiratory phase. His oxygen saturation is 93% on room air. Upon auscultation, he is wheezing bilaterally, and he has an intermittent, nonproductive cough. According to his mother, his past medical history includes only recurrent ear infections and seasonal allergies. His sister, however, has asthma.
Differential Diagnoses:
Asthma exacerbation
Airway obstruction caused by a foreign body
Allergic rhinitis
Viral bronchiolitis
BPD (bronchopulmonary dysplasia)
Diagnosis:
S.T. has a heart rate of 130, a respiratory rate of 52, SpO2 of 93%, a BP of 104/65, and an axillary temperature of 36.1°C. A capillary blood gas reveals the following: pH: 7.33, PaCO2: 38, HCO3: 27. No other labs or tests are ordered at this time.
Treatment:
S.T. needs an albuterol nebulizer treatment as soon as possible. If he responds quickly, than asthma was most likely the cause of his distress. If his issues do not resolve, the MD may want to order a chest x-ray to rule out other diagnoses. A rapid flu and RSV test may also be sent to rule out viral bronchiolitis. Oxygen support may be necessary until the patient is able to maintain an adequate SpO2 on his own.
Outcome:
S.T. was admitted to the pediatric unit to receive nebulized albuterol treatments every 2 hours. Within 48 hours, he had been spaced to treatments every 4 hours, and was discharged home with his parents. He required follow up care with a pulmonologist, who performed peak flow testing and prescribed a daily corticosteroid MDI (metered dose inhaler) as well as a rescue albuterol inhaler. He has relatively infrequent asthma attacks, although he has been hospitalized twice since his initial diagnoses for the same issues. He has also followed up with an allergist, and has been instructed to avoid environmental triggers for asthma, like smoke. S.T.’s prognosis is good, as many children live long, productive lives with the disease, and many even outgrow the condition by adulthood.
Case created by Shelby Taylor, 2011.