Chief Complaint:-Sudden onset of shortness of breath; tightening of the chest and persistent coughing
Subjective: – The patient related, ‘I arose early this morning, took a bath and my medications. I then sat on my front porch in the apartment complex and began viewing the morning scenery towards the roadway. A car was approaching, which seemed to have an exhaust problem because the noise could have been heard in the distance. As it drew nearer I began smelling smoke. When I looked, the car was covered in smoke speeding down the roadway. I tried getting inside before it could reach in front of where I was sitting. Before I could get inside a coughing began and my chest started tightening. I threw myself on the nearby couch and grabbed the ventilator. One hour passed and I got no relief. The symptoms seemed to worsen. Two hours were approaching when I decided to call 911 for help. They arrived within minutes and had me transported to the emergency.’
Objective: – Upon arrival at the emergency even though oxygen was being administered Mr. P.T was still experiencing shortness of breath and tightening of the chest while walking. He was speaking in phrases. Upon examination he appeared slightly cyanosed in the extremities; very anxious; pale in the face; swelling in the lower extremities; strong loud wheezing; persistent coughing and agitation. Mr. P.T has a history of asthma since a child. He is 27 years old.
Assessment: – Assessment is conducted to rule out any other condition besides acute asthma exacerbation. Blood pressure -120/72; Pulse -100; Respiration- 40; Heart rate 100 and Reflexes revealed use of accessary muscles and retractions. ‘Peak Expiratory Flow (PEF) 40-69% of predicted or of personal best O2 Sat >90-95% on room air Arterial Blood Gas (Not typically indicated) PaO2 >60 mmHg on room air PCO2 <42mmHg’ (Camargo, Rachelefsky & Schatz, 2009, p). Lung function tests are mandatory 100% FEV1 or PEF.
Differential diagnoses are Chronic Obstructive Pulmonary Disease (COPD); Upper Airway Obstruction; epiglottitis and intrinsic/extrinsic tracheal narrowing (Camargo et.al, 2009).
Differential Diagnosis Assessment Procedures: – Chronic Obstructive Pulmonary Disease Pulmonary Function Tests (PFT). This test measures how much air the lung can hold. X-ray and CT scans will detect emphysema, which is not associated with acute asthma exacerbations and rules out other lung conditions.
A physical examination for Upper Air way Obstruction shows decrease in breath sounds. There could be wheezing as in acute asthma exacerbations. Also, chocking could occur, which may gimmick acute asthma exacerbation. However, when a bronchoscopy is performed the blockage would become visible if it is a foreign body or mucus plug.
Epiglottitis manifests with stridor, which can be misinterpreted for acute asthma exacerbations because the onset is also sudden. However, the difference is fever, which may not be associated with acute asthma exacerbation. Diagnosis is confirmed during a laryngoscopy revealing inflammation of the epiglottis. A common symptom of intrinsic/extrinsic tracheal narrowing and acute asthma exacerbation is breathlessness. Diagnostic imaging according to Harvey S. Glazer and Marilyn J. Siegel (2013) has been very helpful in confirming a diagnosis ruling out all other conditions, which may have similar presentations. A marked difference is the presence of neoplasms in the trachea, which do not occur in acute asthma exacerbation (Glazer & Siegel, 2013).
Plan: – Treat as an emergency while confirming diagnosis.
Camargo Jr. A. Rachelefsky, G., & Schatz. M. (2009). Managing Asthma Exacerbations in the Emergency Department Summary of the National Asthma Education and Prevention Program Expert Panel Report 3 Guidelines for the Management of Asthma Exacerbations. Proc Am Thorac Soc. 6(4), 357-366
Glazer, H., & Siegel, M. (2013). Chapter 122: Diagnostic Imaging of the Trachea Retrieved March 8th 2013 from http://famona.tripod.com/ent/cummings/cumm122.pdf