Case Study:

Patient with Status

Asthmaticus
Presentation by Kristina Arnold, VALOR Student at
Southern Arizona VA Health Care System

What makes this case

interesting?
Primary Care Visit prior to hospitalization
Code Status
Aminophylline
Status asthmaticus

The Patient
Male patient in his 60s
Past Medical History: COPD, asthma, morbid
obesity, hypothyroidism, and depression

Outpatient clinic visit: Chief complaint of shortness

of breath.
No changes in medication
Instructed to avoid going outside

Hospitalization
Diagnosis: Acute hypoxic respiratory failure Status
asthmaticus

Chief complaint: Shortness of breath, other

symptoms unknown.

Intubated in the ED
Transferred to VA from another hospital
Admitted to the ICU: intubated, sedated, and
stable.

Asthma: Pathophysiology
Inhaled antigens activate immunoglobulin E, mast

cells, and T helper cells in the airway triggering the

production of inflammatory mediators

This perpetuates the inflammatory response

leading to smooth muscle contraction, vascular

congestion, bronchial wall edema, and thick
secretions.

All of these factors cause reduction in the airway

diameter and increase the work of breathing.

Asthma: Pathophysiology
Asthma can range from an acute bronchospasm to
airway inflammation, to permanent airway
remodeling.
Hypertrophy of smooth muscle, new vessel

formation, and increased epithelial goblet cells.

Can lead to nonreversible loss of lung function.

Symptoms
Sensation of chest

Alteration in mental

Cough

Tachycardia

Wheezing

Tachypnea

Prolonged expiration

Pulsus paradoxus

Accessory muscle use

Silent chest

constriction

Paradoxical respiration

status

Status Asthmaticus
Severe asthma attack that does not respond to

typical therapies or usual doses of bronchodilators

and steroids.

Symptoms: hypoxemia, tachypnea, tachycardia,

accessory muscle use, and may or may not have

wheezing.

Mechanical ventilation necessary if patient

becomes acidotic, hypercarbic, or confused in

order to prevent respiratory arrest.

Admission to VA Hospital
Intubated and sedated.
Transferred immediately to ICU.
Drips: propofol and fentanyl
Ventilator mode: Assist Control

Tidal Volume: 350

FiO2: 60%
PEEP: 10
Respiratory rate: 20

Continuous nebulized albuterol with decadron

Clinical Presentation
Respiratory Assessment

Coarse breath sounds bilaterally

Prominent prolonged expiration
End-expiratory wheezing
Scant secretions

Neurology Assessment:
Sedated
Unable to follow commands
PERRLA brisk

Tests and Procedures

ABG upon arrival

pH: 7.45
CO2: 44
O2: 226
HCO3: 24
O2 saturation: 98%

Chest X-ray
Hyperinflation, but no effusions or consolidation.

Pulmonary Function Test

Severe obstruction with bronchodilator response
Significant change in forced expiratory flow suggesting
small airway disease and air trapping.

Nursing Diagnoses
Ineffective Airway Clearance related to

bronchospasms as evidenced by shortness of

breath and wheezing.

Impaired Gas exchange related to decreased

bronchial airflow as evidenced by high levels of

carbon dioxide from arterial blood gas and
prolonged expiration.

Day 1 Interventions
Continued propofol and fentanyl for continued

sedation.
Expected to improve ventilation and prevent further
ventilator dyssynchrony.
Kept to a RASS of -4 or -5

Continuous albuterol nebulizer along with

ipratropium

Solumedrol (methylprednisolone)
Magnesium sulfate

Day 3 & 4 Interventions

Weaning trial attempted
Double stacking breaths
Patient did not tolerate weaning

Sedation medications restarted

Nimbex (paralytic), BiSpectral (BIS) monitoring,

and peripheral nerve stimulator with train of four

added.

Epinephrine drip started to promote

bronchodilation.

Day 5 Interventions
Small improvement with auto PEEP down to 0 with
epinephrine on a low dose

Auto PEEP back up to 2 when off the epinephrine

drip

Nimbex turned off

Day 6
Nimbex and epinephrine drip restarted due to
worsening auto PEEP over night.

No improvement in lung sounds.

Patient remains on propofol, fentanyl, continuous

nebulized albuterol, and ipratropium 4 times a day.

Patient started on aminophylline.

Aminophylline
Bronchodilator smooth muscle relaxation
Suppression of airway stimuli
Limited by the drugs narrow therapeutic index
Only a few studies done on the efficacy for treating
acute COPD exacerbations
2 largest studies have contradictory results

Used when patient not responding to Beta agonist

and corticosteroid therapy.

Day 7
Respiratory Assessment after initiation of
aminophylline
Lung sounds more clear
More air movement
Decreased wheezing

Breathing trial done sedation, epinephrine, and

paralytics weaned off

Ventilator set to CPAP
Some episodes of apnea, but patient starts breathing
again when prompted.

Day 10
Patient extubated
Venti mask at 55% FiO2
Face mask at 5 liters when on albuterol nebulizer.

Outcomes
Eventually sent to long term care
On room air and CPAP at night
Clear/dim lung sounds
Albuterol nebulizer every 4 hours
Budesonide/formoterol 2 puffs as needed

Discussion
Is there anything more that could have been done
in the outpatient clinic to avoid this severe
asthmatic exacerbation from occurring?

Code status are there better strategies we can

implement to be aware of a code status before
intubation?

How will this hospitalization effect his mental

health?

Should more research be done on Theophylline and

its effects in patients with this same diagnoses?

Acknowledgements
Jennifer Sinclair, RN

References
ANDERSON, E., & EMERMAN, C. L. (2000). Managing acute exacerbations of chronic obstructive pulmonary
disease.The Journal of Critical Illness,15(12), 674. Retrieved from
http://go.galegroup.com.ezproxy4.library.arizona.edu/ps/i.do?id=GALE
%7CA76665401&sid=summon&v=2.1&u=uarizona_main&it=r&p=ITOF&sw=w&asid=b2feaddfbda31439c3d
db4c9fbaa4795
Cydulka R.K. (2016). Acute Asthma. In Tintinalli J.E., Stapczynski J, Ma O, Yealy D.M., Meckler G.D., Cline
D.M. (Eds), Tintinallis Emergency Medicine: A Comprehensive Study Guide, 8e. Retrieved July 27, 2016
from http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=1658&Sectionid=109429684

Micromedex. (2016). Albuterol Sulfate. Retrieved from http://www.micromedexsolutions.com/micromedex2/

librarian/PFDefaultActionId/evidencexpert.DoIntegratedSearch#
Micromedex. (2016). Aminophylline. Retrieved from http://www.micromedexsolutions.com/micromedex2/
librarian/PFDefaultActionId/evidencexpert.DoIntegratedSearch#

Micromedex. (2016). Ipratropium Bromide. Retrieved from http://

www.micromedexsolutions.com/micromedex2/librarian/PFDefaultActionId/
evidencexpert.DoIntegratedSearch#

Micromedex. (2016). Methylprednisolone Sodium Succinate. Retrieved from http://

www.micromedexsolutions.com/micromedex2/librarian/CS/274FFE/ND_PR/
evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/92C909/
ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/
ND_T/evidencexpert/PFActionId/evidencexpert.GoToDashboard?
docId=372800&contentSetId=100&title=Methylprednisolone+Sodium
+Succinate&servicesTitle=Methylprednisolone+Sodium
+Succinate&brandName=Novaplus+SOLU-Medrol#
Micromedex. (2016). Magnesium Sulfate. Retrieved from http://
www.micromedexsolutions.com/micromedex2/librarian/PFDefaultActionId/
evidencexpert.DoIntegratedSearch#