Case Based Learning for June 2025

A 53-year-old female with past medical history of type 1 diabetes, asthma, anxiety, and depression, was brought in by EMS with CPR in progress. She called EMS with complaint of difficulty breathing. When EMS arrived, patient was talking and using a nebulizer treatment. Shortly after their arrival, she became unresponsive, apneic, and pulseless. CPR was initiated. An iGel was placed and Lucas chest compression device was placed. On rhythm check, no shock was advised.

On arrival to the hospital, SpO2 was 55%, despite bilateral breath sounds and 100% oxygen and adequate bagging. An IV was placed and patient was given Narcan 2 mg, SoluMedrol 125 mg, and magnesium sulfate 2 g IV. She also received epinephrine 0.3 mg IM and a DuoNeb inline.  On rhythm check, sinus tachycardia with a pulse was noted and compressions discontinued. Patient continued to have only agonal respirations. The iGel was removed and she was intubated using etomidate and rocuronium. Her heart rate and blood pressure were increasing and a second dose of etomidate was given while a ketamine infusion was being initiated.

EKG showed sinus tachycardia with rate 121 and RBBB. There was also ST depression in the inferior leads and inverted T waves in the lateral leads.  CXR showed ETT in good position 3 cm above the carina and no infiltrates or effusions.

Labs: WBC 15.6, H/H 14.2/45.0, plt 322.  INR 1.0, PTT 33.0, dimer 812 (normal 100-599). VBG pH 6.786, pCO2 104, pO2 47, HCO3 15.8, O2 sat 41%. K 5.6, anion gap 23.6. Glucose 399. Trop-I (high sensitivity) 153.

After receiving the VBG results, the patient was given bicarb 1 amp. Increased ventilatory rate was used to decrease ETCO2 down to the 40s. Accepting intensivist requested CT head and CTA chest/abd/pel and recommended 2 more amps of bicarb and ceftriaxone be given.

There was time to get CTs prior to Life Flight arrival. CT head was unremarkable. CTA C/A/P showed no PE, no other vascular abnormality. There was small L pneumo and moderate band opacities in bilateral lungs c/w atelectasis and/or pneumonia/aspiration. There were also nondisplaced fractures of multiple bilateral anterior ribs.

The patient was noted to have increased pressures on the vent and return of bilateral wheezing and was given another in-line DuoNeb, epi 0.3 mg SQ, and mag sulfate 2 g IV upon arrival of Life Flight.

Discussion: Asthma exacerbations can be life threatening and lead to respiratory arrest and cardiovascular collapse. Danger signs include accessory muscle use, fragmented speech, inability to lie supine, diaphoresis, agitation, though the situation can still be life threatening without these. Cyanosis, hypoxia despite high flow O2, decreased LOC, and slow breathing or weak effort are signs of imminent arrest. Get your favorite mode of intubation ready!

Here are some options for treatment of these patients with severe asthma exacerbation:

• Noninvasive ventilation can be helpful. NIV is not as well studied in asthma as it is in COPD and heart failure but has been shown to have some benefit and may prevent intubation.
• Oxygen to maintain SpO2 >92% (>95% in pregnancy). SpO2 <95% despite high flow O2 by NRB is a sign of imminent respiratory arrest or severe complications, like pneumothorax.
• Inhaled beta-agonists are the mainstay of treatment. Ideally, continuous nebulization of albuterol to a dose of 10-15 mg (4-6 standard nebs) over an hour is given. In this small facility, there is no way to provide inline nebs due to equipment on hand (but it was rigged with ED ingenuity and lots of tape).
• Inhaled ipratropium can also be given every 20 minutes x 3 then every hour x 3, if needed.
• IV glucocorticoid is also essential to reduce airway inflammation and mucus plugging. Inhaled glucocorticoid is not effective for severe exacerbations.
• IV magnesium sulfate 2 g infused over 20 minutes is also recommended. Some studies have shown no significant beneficial outcome, but they excluded possible life-threatening exacerbations, so its use is still recommended in severe cases.
• Epinephrine (0.3-0.5 mg IM) or terbutaline (0.25 SQ) q 20 min up to 3 doses can be used in patients unable to use inhaled bronchodilators. Epi should be used if anaphylaxis is the cause of the exacerbation (obvi)
• There are some reports of inhaled anesthetics (halothane, isoflurane, or sevoflurane) being helpful if you are lucky enough to have them and a CRNA in your facility.
• IV ketamine in a bolus of 0.5- 1 mg/kg followed by drip of 0.4- 2 mg/kg/hr in people with severe exacerbations showed improvement in the ICU in 30 minutes to several hours, with added benefit of being moderate sedation so can be done in ED and ICU rather than the OR.
• Heliox was thought to be an option but there is so much conflicting data that it is no longer recommended.
• Things to definitely not use (ineffective treatments):
  • Leukotriene receptor agonists (montelukast), unless event was triggered by aspirin or NSAID ingestion
  • Methylxanthines (theophylline, aminophylline)
  • Antibiotics

Here is a link the the entire UpToDate page, if you would like to read more.

Acute exacerbations of asthma in adults: Emergency department and inpatient management

Written by Sara Ragsdale, DO
ERx Clinical Partners Medical Director, Providence St Joseph’s Hospital, Dayton General Hospital,
Associate Professor, Department of Medical Education and Clinical Sciences, Elson S Floyd College of Medicine, Washington State University

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This is for informational purposes only. For medical advice or diagnosis, consult a physician.

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