_ y/o _ with PMH _asthma, presents with wheezing and SOB.
Onset _.
Previous treatment tried: _.
Aggravating factors: _.

Asthma history includes _.

No hx of other pulm pathology (e.g. cystitic fibrosis, immunodeficiency) 

Exam: _
     _ aeration
    _ inspiratory wheezes
    _ expiratory wheezes
    _ cyanosis
   _ rhochi



MDM (with A/P):

Suspect asthma exacerbation

-Will administer empiric treatment, frequently re-evaluated, and utilize objective validating scores method Respiratory Score (RS) to track trajectory to inform need (or lack thereof) for further treatment and appropriate disposition. 
-Monitored on pulse ox
-Supplemental O2 PRN goal O2 >90%

Initial Evaluation of Severity: 
     RS 1-4
_ albuterol 3 nebs/hr, dexamethasome
              RS 6-12
                  _ albuterol 3 nebs/hr, ipatropium 3 nebs/hr, dexamethasome

Start of 2nd Hr Evaluation:
RS 1-4 (and given 1st hr RS 1-5), pt appropriate for discharge
RS 1-4 (and given 1st hr RS 6-9), obs x1 hr
RS 1-4 (and given 1st hr RS 10-12), obs x2 hr

RS 5-8, albuterol 3 nebs/hr
RS 9-12 albuterol 3 nebs/hr, ipratropium, mag 50mg/kg (max 2 g)

Start of 3rd Hr Evaluation:
          RS 1-4, discharge
          RS 5-8, albuterol 3 nebs/hr, ipratroprium
          RS 9-12
               Continous albuterol
               Magnesium if not already administered
               Admit to ICU

Start of 4th Hr Eval:
          RS 1-8 Admt to inpt
          RS 9-10 Albuterol continous
                    Admit to ICU v floor
          RS 11-12 Admit to ICU

_ Status Asthmaticus –  Given status asthmaticus and deterioration, escalating intensity of medical interventions including were administered:
-albuterol/ipratropium PRN 3x/hr (5mg/0.5mg for >=5 y/o) (2.5m/0.25mg for <5 y/o).     
-dexamethasome 0.6 mg/kg IV/PO (16mg max) OR prednisone 2mg/kg PO (0mg max) OR methyprednisolone 2mg/kg IV (max 125mg IV)
mag 50mg/kg IV (max 2g)
-epinephrine 0.01mg/kg SQ (max 0.3mg SQ)
-terbutaline 0.01mg/kg IV / 10 min (max 0.5mg) then infusion at 0.4mcg/kg/min
-ketamine 1mg/kg IV, then 1mg/kg/hr

DDx (considered and doubt):  There is a small but finite risk for the following processes though the patient does not meet our criteria for further diagnostics nor empiric treatment given the that patient’s presentation is not adequately consistent with the constellation of findings characteristic to these pathologies (as detailed parenthetically below):

-PNA (rhonchi on pulm exam, fever, persistant hypoxia/tachypnea/dyspnea, lack of improvement with asthma tx)
 _ CXR not generally indicated for asthma exacerbation (indications sufficient constellation of s/s c/f PNA: febrile, rhonchi on pulmonary exam, not following expected course with initial ED treatment)
-myocarditis (refractory to ED management for asthma, infectious symptoms, signs of cardiac shock)
-foreign body (hx c/f fB ingestion, stridor, etc)

_ Home given marked improvement in respiratory clinical parameters after initial management (first 1-2 hours in ED) – diminished/absence of wheezing/retracting and increased aeration for >1 hr after last albuterol dose when initial presentation of low severity and prolonged observation when initial presentation moderate severity. Family/patient provided with asthma action plan and educated on precipitants and methods to decrease frequency of exacerbations. Advised to follow up with primary care doctor tomorrow for re-check of symptoms. Return precautions discussed including recurrence of wheezing, signs of respiratory distress including belly breathing, retractions. Pt/family amenable to plan.

_ Observation given respiratory non-critical but refractory to initial ED treatment
_ Admitted (given inadequate response to ED initial management for safe disposition home)


If poorly controlled asthma and only on albuterol, asthma controller steroid (first line at our facility):
-pulmocort (bedesonide nebulizer)
-flovent (fluticasone inhaler)


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