CLINIC EMERGENCIES Respiratory

1. CLINIC EMERGENCIESRespiratory Susana A. Alfonso, M.D. Assistant Professor Department of Family and Preventive Medicine Emory University August 9, 2007

2. Learning Objectives • Identify a patient in respiratory distress • Assess the severity of an asthma exacerbation • Implement immediate treatment • Assess the patient’s response to therapy • Plan for appropriate disposition of the patient

3. Case Number 1 • A 3 month old male is brought in by his mother and grandmother for a weight check. This baby was born at 27 weeks gestation. His neonatal course was complicated by intubation secondary to respiratory distress. After extubation he was noted to have persistent RUL atelectasis. He was discharged on home nebulizations of Xopenex (levalbuterol) which were recently discontinued. He is being followed by Pulmonary and has been doing well at home. His first visit to our office was 4 weeks ago for a well baby check where he was found to be doing well. After appropriate immunizations were given he was told to follow up today. His mom states he has been well, however last night she thought she heard him wheezing.

4. WHAT DO YOU DO? • IS THIS PATIENT HIGH OR LOW RISK • ASSESS SEVERITY • TREAT • REASSESS • DISPOSE

5. Risk Factors • Prematurity • History of mechanical ventilation with risk of subsequent bronchopulmonary dysplasia • Unresolved RUL atelectasis • Recent withdrawal of medication

6. ASSESS SEVERITY • Always start with the ABC’s • Always look at the vital signs (they are called vital for a reason) • Assess severity: This is done either with FEV1, PEF, or in our patient with clinical signs. • FEV1or PEF<50% of predicted/personal best is severe • FEV1 or PEF 50-80% of predicted/personal best is moderate • FEV1or PEF >80% is mild • Accessory muscle use, chest retractions, nasal flaring, all indicate a severe exacerbation

7. Vital Signs: HR 160, RR 60 BP not done, Temp. afebrile Gen: WD, WN, crying HEENT: NC, AT, nasal flaring noted, mucous membranes moist Neck: supple, no LAD Lungs: Air entry not clearly discernable because of crying. However, after giving the patient a pacifier, wheezing was heard with decreased air entry. No crackles. CV: tachy, regular, without murmurs or gallops, cap refill <2 sec Chest wall: intercostal retractions noted Abdomen: use of abdominal wall musculature noted, good BS, soft, no masses Physical Exam

8. Initial Treatment • Nebulized B2 agonist • O2 to keep Pulse oximetry >90% (95% in the pregnant patient) If pulse ox is not available then give to all patients believed to have a moderate to severe exacerbation • Consider oral corticosteroid early

9. Supplemental Therapies • Anticholinergics may cause additional bronchodilation especially in severe obstruction • Antibiotics are only recommended for co morbid conditions (pneumonia) • Hydration may be beneficial • Chest PT is not recommended • Mucolytics are not recommended • Sedation is not recommended

10. Ongoing Assessment • Identify precipitating events • Identify complications (pneumonia, pneumothorax, pneumomediastinum) • Rule out upper airway obstruction. Listen for dysphonia (wheezing that is monophonic or loudest over the central area)

11. Re-examine the patient • The first nebulization treatment usually takes 5-10 minutes • PE: Vitals, clinical signs of respiratory distress, Pulse ox, and PEF or FEV1 • Repeat nebulization treatment. It may either be given as a “continuous” treatment or every 20-60 minutes. Repetitive or continuous administration produces incremental bronchodilation

12. Reassess • Initial response to treatment is a better predictor of the need for hospitalization than is the severity of an exacerbation on presentation. Measurements of airflow at 30, 60, and 90 minutes can help reduce unnecessary admissions • However, PEF values less than 30% which improve by less than 10% are indicative of an increased risk of life threatening deterioration

13. Good Response • PEF or FEV1> 70% predicted/personal best. Response is sustained for 60 minutes after treatment. PE normal with no evidence of distress • May discharge patient home with continued inhaled B2 agonist and corticosteroid • Patient education: review medicine use, action plan, and follow up

14. Incomplete Response • FEV1or PEF >50% but <70% • Abnormal PE with abnormal vital signs or physical exam • Decision to hospitalize should be based on duration and severity of symptoms, course and severity of prior exacerbations, access to medical care, adequacy of support and home conditions and presence of psychiatric illness

15. Poor Response • FEV1 or PEV <50% • PE continues to show evidence of respiratory distress, patient drowsy, confused • Admit to hospital and consider ICU care with ABG, CXRAY, CBC, electrolytes, ECG in a patient older than 50 YOA or with coexistent heart disease of COPD, IV corticosteroids and mechanical ventilation. There is conflicting evidence with regard to the use of Mg

16. Case Number 2 • Anna is a 91 year old female with a long history of asthma. In addition she has HTN, OA, and AS. She has been on various regimens with variable success. She has refused to see a pulmonologist. • She comes into your office complaining of increased SOB for the last three days. Denies F/C, sputum production but does admit to nasal congestion, itchy, watery eyes, scratchy throat ever since her granddaughter brought home her new pet cat. The patient lives with her granddaughter. The patient states she had been taking the Albuterol MDI, Flovent, Serevent, and Singulair as prescribed. She did not use her nebulizer because she ran out of meds. She has not had oral corticosteroids in 3 months.

17. HIGH OR LOW RISK PATIENT? • ASSESS SEVERITY • TREAT • REASSESS • DISPOSE

18. VS: P85 RR20 T afebrile BP 140/85 Peak flow 180 (personal best 220) SaO2 is 96% on RA Gen: WD, thin, female in a wheelchair, smiling HEENT: NC/AT PERRL, TM pearly grey, nares with significant edema, pale, min. white discharge, OC/OP with small amt. white drainage noted Neck: supple, no LAD CV: RRR with a III/VI systolic murmur heard best at the right 2nd intercostal space Lungs: markedly decreased air entry with wheezing in all fields, no crackles Physical Exam

19. Assess Severity • VS are normal • PEF is >80 of personal best although diminished (normal for her height of 5’1 is 350) • PE while quite remarkable for wheezing was not that changed • ………Mild exacerbation

20. Immediate Treatment • Albuterol sulfate nebulization

21. Assess Patient’s Response • After initial treatment VS remained essentially unchanged however pt. stated she felt better. PEF increased to 200. PE was essentially unchanged

22. Disposition of Patient • Patient was sent home with a prescription for nebulized albuterol sulfate, a course of oral corticosteroid, and an H1 blocker • I advised the patient to check her peak flows q am and to continue her current regimen with the long acting B2 agonist and Singulair but to hold the inhaled steroid (you can continue the inhaled steroid) and Albuterol MDI while she was using the nebulized Albuterol. • I asked the patient to follow up in three days and she said she would call me and let me know how she was doing. She did not like coming in.

23. Case Number 3 • KF is a 32 year female with no known medical problems who was seen in our office 1 week ago c/o cough. She was diagnosed with bronchitis and allergic rhinitis and treated with an antibiotic, allegra, and flonase. She returns today because of progressive SOB, cough productive of yellow sputum, and fatigue. She denies fever or chills and states she has been taking her medications as prescribed.

24. VS: T 96.9 P90 RR40 BP80/60 SaO2 90%on RA Gen: ill appearing female, thin, well developed, visibly short of breath, no accessory muscle use noted HEENT: NC/AT PERRL, TM’s/nares benign, OC/OP benign Neck: supple, no LAD CV: RRR s M,G, or R Lungs: decreased air entry with wheezing in all fields, crackles at the right base, no egophany, increased tactile fremitus at the right base Physical Exam

25. Assess Severity • PEF was not done initially • VS are abnormal, pt is hypoxic, little air entry is noted on exam, pt. is visibly struggling to breathe…..severe exacerbation

26. Immediate Treatment • 2.5-5.0mg Albuterol sulfate in 3cc normal saline with or without 0.5mg ipratropium bromide by nebulizer. Alternatively you may use 6-12 puffs of Albuterol MDI or Combivent • O2 by nasal cannula 2-4L/min

27. Assess patient’s response • After 5 minutes pt. BP is 96/70 no pulsus paradoxus P 120 T same RR40 SaO2 is 94% on 4L/min. Lung exam is essentially unchanged • PEF is 200 (predicted is 460’s) • Patient’s response is poor

28. Ongoing Treatment • Albuterol sulfate neb with or without iprotroprium bromide • O2 • Consider oral corticosteroid

29. Disposition of Patient • A patient with a severe exacerbation with a poor response to treatment needs to be hospitalized with consideration given to ICU care

30. The rest of the story… • KF was noted to have responded poorly to initial treatment. While ongoing treatment was given an ambulance was called for transport to CWL. • Her SaO2 dropped to 88-90% on 4L/min and she complained of drowsiness • Transport arrived and was instructed to take the patient emergently across the street to Dunwoody Medical Center • One and ½ hours later I went to see her in the ED. She had responded well to three treatments of Xopenex, continued O2, and IV corticosteroids. A RA blood gas was being drawn during my visit.

31. Summary • IS THIS PATIENT HIGH OR LOW RISK • ASSESS SEVERITY • TREAT • REASSESS • DISPOSE

32. References • Behrman, Kliegman, and Jenson. Nelson Textbook of Pediatrics, 16th ed. Philadelphia, W.B. Saunders, 2000, pgs.668-672. • Emond S, Camargo C, and Nowak R. 1997 National Asthma Education and Prevention Program Guidelines: A Practical Summary for Emergency Physicians. Annals of Emergency Medicine 1998;31(5):579-589.