JR is a 56 yo man with h/o asthma, HTN and hyperlipidemia. He presents to the ER today with h/o shortness of breath for 45 minutes at rest. He reports that he was feeling well and in his usual state of health until about an hour ago, when he smelled something burning. 20 minutes later, he began to feel short of breath and was wheezing. He tried using his albuterol inhaler without success, so he proceeded to the ER. Upon arrival, he was tachycardic, tachypneic, wheezing, using accessory muscles and hypertensive. His last admission for an asthma attack was 2 months ago. He denies a recent cold or URI and says the albuterol usually helps him when he feels an attack coming on and tends to use it on a daily basis. He generally has wheezing and shortness of breath on a daily basis. JR reports poor sleep due to waking about 2 times a week for shortness of breath. He has 2 cats, which sleep next to him on his pillow and he lives in an apartment complex. JR does not smoke, but his neighbor smokes. JR is a carpenter by occupation. He monitors his peak flow once a week at home. He reports that his peak flow generally runs about 325 L/min and his personal best is 480 L/min. His current peak flow is 175 L/min. Medication Prior to Admission: Albuterol MDI 2 puffs BID-QID PRN Salmeterol Diskus 1 inhalation QID Ipratropium bromide MDI 2 puffs QID Lovastatin 20 mg po HS Lisinopril 10 mg po QD Questions:

1. What are the possible causes of JR’s acute shortness of breath?

There are several potential causes for JR’s acute shortness of breath. Given his history of asthma, one possibility is an exacerbation of his underlying condition. Asthma attacks can be triggered by various factors including allergens, irritants (such as smoke), respiratory infections, and stress. In this case, the onset of symptoms after exposure to a burning smell and the associated wheezing and use of accessory muscles are consistent with an asthma exacerbation.

Another potential cause to consider is an allergic reaction. JR’s symptoms of shortness of breath, wheezing, and tachycardia may be indicative of an anaphylactic reaction. Allergens from the environment, such as pet dander or smoke, can trigger a severe allergic response in susceptible individuals.

Additionally, it is important to consider other respiratory conditions such as chronic obstructive pulmonary disease (COPD), which can present with similar symptoms to asthma. JR’s history of smoking exposure (through his neighbor) and his occupation as a carpenter may suggest an increased risk for developing COPD.

2. What further evaluation would you recommend for JR?

JR’s presentation warrants further evaluation to determine the underlying cause of his acute shortness of breath. Initial assessment should include a detailed history and physical examination. This can help identify any potential triggers or exacerbating factors, as well as provide clues to other respiratory conditions or comorbidities.

Given JR’s symptoms and his history of asthma, pulmonary function testing (PFT) is crucial. This will assess his lung function and help confirm the diagnosis of asthma and determine the severity of his condition. PFT measures, such as spirometry or peak flow measurements, can be used to evaluate his respiratory airflow and assess the degree of bronchial obstruction.

In addition to PFT, further laboratory testing may be indicated. Complete blood count (CBC) can help identify any signs of infection or allergic response. Serum IgE levels can also be measured to assess for an allergic component. If an allergic reaction is suspected, testing for specific allergens may be considered to identify potential triggers.

It is also important to evaluate JR’s cardiovascular status, given his history of hypertension and tachycardia on presentation. An electrocardiogram (ECG) can help assess for any cardiac abnormalities or signs of ischemia.

To further understand the triggers for JR’s symptoms, an environmental assessment should be conducted. This may involve assessing the air quality of his apartment complex, including the presence of any irritants or allergens. It may be beneficial to evaluate JR’s exposure to secondhand smoke and potential occupational exposures.

3. How would you manage JR’s acute exacerbation of asthma?

The management of an acute exacerbation of asthma involves relieving symptoms, improving airflow, and preventing further deterioration. In JR’s case, since he has already tried his rescue medication (albuterol) without success, additional interventions are necessary.

First, it is important to ensure adequate oxygenation. Supplemental oxygen should be provided to maintain oxygen saturation levels above 90%. This can be achieved using a nasal cannula or a face mask depending on the severity of JR’s symptoms.

Next, bronchodilators should be administered to relieve bronchial obstruction and improve airflow. Short-acting beta-agonists, such as albuterol, are the preferred initial choice for acute asthma exacerbations. Inhaled ipratropium bromide, a short-acting anticholinergic, may also be considered as an adjunctive therapy.

If JR’s symptoms do not improve with bronchodilators alone, systemic corticosteroids should be initiated to reduce airway inflammation. This can be done orally or intravenously depending on the severity of the exacerbation. Corticosteroids help reduce airway inflammation and prevent further deterioration of lung function.

Lastly, it is important to address any potential triggers or exacerbating factors. In JR’s case, efforts should be made to minimize exposure to smoke, including secondhand smoke from his neighbor. If his asthma symptoms are exacerbated by allergens, such as pet dander, he may need to consider making changes to his living environment or taking steps to reduce his exposure.

Overall, the management of JR’s acute exacerbation of asthma requires a combination of pharmacological interventions, careful monitoring, and addressing any modifiable triggers or exacerbating factors. Close follow-up should be arranged to monitor his response to treatment and assess his lung function over time.