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Difficulty: EasyPulmonary and Critical Care

A 28-year-old woman presents to an urgent care center with a two-day history of progressive shortness of breath, chest tightness, and a dry cough. Her symptoms began shortly after she adopted a cat. She was diagnosed with asthma in childhood but has not required daily medications for the past five years. Over the last 48 hours, she has used her short-acting albuterol inhaler up to six times daily with minimal relief. Her temperature is 37.1°C (98.8°F), blood pressure is 122/78 mmHg, pulse is 112/min, and respiratory rate is 24/min. Pulse oximetry shows an oxygen saturation of 93% on room air. Physical examination reveals a prolonged expiratory phase with diffuse bilateral wheezing. There is no jugular venous distention, and heart sounds are normal without murmurs or gallops. Which of the following is the most appropriate next step in pharmacologic management?

  1. Administration of systemic corticosteroidsAnswer
  2. B
    Administration of intravenous furosemide
  3. C
    Measurement of serum B-type natriuretic peptide
  4. D
    Prescription of oral levofloxacin
  5. E
    Administration of intravenous piperacillin-tazobactam

Answer

Administration of systemic corticosteroids
This patient is presenting with an acute asthma exacerbation directly triggered by recent exposure to an environmental allergen (cat dander). Her lack of clinical improvement despite frequent use of a short-acting beta-agonist indicates a moderate-to-severe exacerbation. In such cases, the standard of care dictates the addition of systemic corticosteroids (such as oral prednisone). Corticosteroids address the underlying severe airway inflammation, accelerate symptom resolution, and significantly decrease the risk of treatment failure or relapse. She does not have signs of volume overload or an infectious etiology, making alternative treatments inappropriate.

Step-by-Step Solution

1
Identify the primary diagnosis based on the clinical presentation.
The patient is experiencing an acute asthma exacerbation triggered by an environmental allergen (cat dander).
She has a history of asthma, recent exposure to a known trigger, tachypnea, and diffuse expiratory wheezing.
2
Determine the severity and the patient's response to initial home therapy.
The exacerbation is moderate to severe, as evidenced by the lack of improvement despite using a short-acting beta-agonist frequently over 48 hours.
Repeated use of an albuterol inhaler without symptom resolution indicates significant underlying airway inflammation that requires escalation of therapy.
3
Select the most appropriate pharmacological intervention for this severity.
Systemic corticosteroids (e.g., oral prednisone) are indicated.
Systemic corticosteroids effectively reduce severe airway inflammation, accelerate symptom resolution, and decrease the risk of a relapse.

Key Concept

The management of an acute asthma exacerbation that is unresponsive to initial short-acting beta-agonist therapy requires the prompt administration of systemic corticosteroids.
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Topics

Pulmonary and Critical Care

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