â€œMy daughter has had a bad fever, and now she is having trouble breathing, andÂ Â albuterolÂ doesnâ€™t help.â€
Terri Collins is an 8-year-old African-American girl who presents to the ED with a 2-day history of fevers, malaise, and nonproductive cough. The mother gaveÂ Â acetaminophenÂ andÂ Â ibuprofenÂ to help control the fever. Mother stated that â€œa lot of other kids in her class have been sick this fall, too.â€ Terri started having trouble breathing the morning of admission, and the mother gave herÂ Â albuterol, 2.5 mg via nebulization twice within an hour. Terri still sounded wheezy to the mother after theÂ Â albuterol, and Terri stated it was â€œhard to breathe.â€ Terri was previously well controlled regarding asthma symptoms. Previous clinic notes reported symptoms during the day only with active play at school or at home and rare nighttime symptoms. She uses PRNÂ Â albuterolÂ to help with symptoms after playing. Her assessment in the emergency department revealed Terri to have labored breathing, such that she could only complete four- to five-word sentences. She had subcostal retractions, tracheal tugging with tachypnea at 54 breaths/min. Her other vital signs were a heart rate of 160 bpm, blood pressure of 115/59, temperature of 38.8Â°C, and a weight of 22.7 kg. The initialÂ Â oxygenÂ saturation was 88%, and she was started onÂ Â oxygenÂ at 1 L/min via nasal cannula. Bilateral expiratory and inspiratory wheezes were noted on examination. A chest x-ray revealed a right lower lobe consolidation consistent with pneumonia and possible effusion. After receiving threeÂ Â albuterol/Â ipratropiumÂ nebulizations, her breath sounds and oxygenation did not improve, so she was started onÂ Â albuterolÂ via continuous nebulization at 10 mg/hr and herÂ Â oxygenÂ was titrated to 3 L/min. She was also given a dose of 25 mg IVÂ Â methylprednisoloneÂ and a dose of 600 mg IV magnesium sulfate. Terri was then transferred to the PICU for further treatment and monitoring.
Asthma; last hospitalization 4 years ago, and has had two courses of oral corticosteroids in the past year
Asthma on fatherâ€™s side of the family
Lives with mother, father, and two siblings, both of whom have asthma. There are two cats and a dog in the home. Father is a smoker but states that he tries to smoke outside and not around the kids. She is in the second grade and is very active on the playground.
AlbuterolÂ 2.5 mg nebulized Q 4â€“6 H PRN wheezing
FluticasoneÂ propionate 44 mcg MDI two puffs BID
AcetaminophenÂ 160 mg/5 mLâ€”10 mL Q 4 H PRN fever
IbuprofenÂ 100 mg/5 mLâ€”10 mL Q 6 H PRN fever
(+) Fever, cough, increased work of breathing
Alert and oriented but in mild distress with difficulty breathing
BP 125/69, P 120, T 37.9Â°C, RR 40, O2Â sat 94% on 3 L/min nasal cannula
Soft, supple, no cervical lymphadenopathy
Wheezes throughout all lung fields, still with subcostal retractions
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|Na 141 mEq/L||WBC 34.2 Ã— 103/mm3|
|K 3.1 mEq/L||â€ƒNeut 91%|
|Cl 104 mEq/L||â€ƒLymph 5%|
|CO2Â 29 mEq/L||â€ƒMono 4%|
|BUN 16 mg/dL||RBC 5.07 Ã— 106/mm3|
|SCr 0.52 mg/dL||Hgb 13 g/dL|
|Glu 154 mg/dL||Hct 41%|
|Plt 310 Ã— 103/mm3|
Respiratory viral panel nasal swab: positive for influenza A
Asthma exacerbation with viral pneumonia
1.Â What additional information is needed to fully assess this patient?
2.Â What nondrug therapies might be useful for this patient?
3.Â Develop a plan for follow-up that includes appropriate time frames to assess progress toward achievement of the goals of therapy.
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