Asthma exacerbation with carbon dioxide retention

Author: V. Dimov, M.D., Allergist/Immunologist and Assistant Professor at University of Chicago
Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at LSU (Shreveport) Department of Allergy and Immunology

A 46-year-old African American female (AAF) with h/o asthma presented to the ER with shortness of breath. This was her 3rd ER visit in the last ten days. She stated that her typical triggers are pet hair and dust. She was sitting in the park this afternoon and developed shortness of breath. Her boyfriend immediately brought her to the ER for evaluation. Five days ago, she was sent home with Prednisone, Advair and albuterol and stated that had been compliant with the medications. She admitted to cocaine use after discharge, but denied any chest pain. She also denied any fever, chills, hemoptysis, leg pain/swelling, productive cough but reported rhinorrhea for 3 days.

Past medical history (PMH)

Asthma

Medications

Prednisone 20 mg po qd, fluticasone-salmeterol (Advair) 250-50 mcg BID, albuterol PRN

Social history (SH)

Smoking in the past, current cocaine use

Family medical history (FMH)

Asthma in her mother

Physical examination

Vital signs 110/67-110-98.2 °F (36.8 °C)-28- 89% on RA
General appearance: moderate distress, cachectic, frail, acutely ill, disheveled.
ENT: Oropharynx clear, no plaques or exudates
Respiratory: Diminished breath sounds. Extensive wheezing throughout.
Cardiovascular: no murmurs, no rubs, no gallops
Gastrointestinal: soft, NT, ND, no organomegaly, + BS
Genitourinary: No CVAT
Musculoskeletal: No c/c/e, no calf tenderness, normal ROM, equal palpable peripheral pulses and normal strength
Skin: no rashes noted.

What is the most likely diagnosis?

Asthma exacerbation due to URTI and cocaine abuse

What tests would you suggest?

- CXR
- ABG
- CBCD, BMP
- Urine toxic screen

What happened?

ABG showed pH of 7.36, PaCO2 50, PaO2 107, HCO3 28.

She was given continuous nebulized albuterol with symptomatic improvement. Her respiratory rate decreased to 22, HR 76, O2 sat was 99% on room air. She still continued to have pursed lip exhalations.

CXR: Lungs were mildly hyperinflated, but clear of infiltrate, effusion or pneumothorax. CBCD and BMP were unremarkable.

She was admitted to internal medicine and treatment with Methylprednisolone 40 mg iv q 6 hr and albuterol UD q 4 hr was started.

What happened next?

The patient improved rapidly and was discharged 2 days later. She admitted to not using her Advair. SW was involved and a follow-up with PCP was arranged. She was advised to stop using cocaine. Discharge medications included prednisone taper, Advair, Albuterol PRN.

Final diagnosis

Asthma exacerbation with carbon dioxide retention. Asthma is the most common chronic respiratory disease, affecting up to 10% of adults and 30% of children (JACI, 2011).

Related reading

Acute Asthma - Lecture Notes. Life in the Fast Lane Emergency Medicine Blog, 11/2008.

Published: 09/13/2007
Updated: 11/25/2011