Rosen & Barkin's 5-Minute Emergency Medicine Consult (785 page)

• A whistling sound made while breathing:
  
  • Diffuse:
    
    • As with reactive airway disease or pulmonary edema
      
  • Focal:
    
    • As with pneumonia or pulmonary embolism
      
• Dyspnea
  
• Respiratory distress
  
• Chest pain
  
• Cough
  
• Sputum production:
  
  • Frothy (pulmonary edema)
    
• Stridor
  
• Fever
  
• Cyanosis
  
• Tachypnea
  
• Tachycardia
  

• Current URI:
  
  • Rhinoviruses implicated in reactive airways
    
• Recent exercise:
  
  • Exercise-induced asthma, vocal cord dysfunction
    

• Mental status:
  
  • Lethargy, confusion, and fatigue in the setting of respiratory distress are the primary reasons for airway management.
    
• Presence of muscle retractions
  
• Lung auscultation
  

• Pulse oximetry:
  
  • Useful for assessing severity, but not for predicting hospital admission
    
• Peak flow:
  
  • Useful in assessing need for hospitalization
    
• CXR
  

• ABG:
  
  • Sometimes used to determine whether patient is fatiguing by noting falling oxygenation, rising CO
    ₂
    , and acidosis
    
  • Clinical assessment is a more reliable indicator of the need for airway management.
    
• WBC:
  
  • Elevated WBC does not distinguish infection from other disorders, as stress causes demargination.
    
  • WBC is also elevated in noninfected patients taking steroids.
    
  • A normal WBC does not rule out an underlying pneumonia.
    

• Peak expiratory flow (PEF):
  
  • To assess function of small airways
    
  • Use to determine severity and track the progress of therapy in patients with reactive airway disease.
    
• CXR:
  
  • Assess for diagnosis of pulmonary conditions:
    
    • Pneumonia
      
    • Foreign-body aspiration
      
  • Assess for pulmonary edema.
    
• EKG:
  
  • Useful when patient is at risk for cardiac ischemia
    
  • Indicated in all cases in which wheezing is caused by pulmonary edema
    
• Soft-tissue neck:
  
  • Used to assess for foreign body or obstructing mass
    

Laryngoscopy/bronchoscopy:

• Indicated when obstruction is thought to be causal
  
• Used to retrieve an inhaled foreign body or diagnose an underlying tumor
  

See Etiologies.

TREATMENT

• Supplemental oxygen
  
• Initiate pulse oximetry and cardiac monitoring.
  
• Initiate therapy for underlying condition when indicated:
  
  • Asthma
    
  • Pulmonary edema
    
• Intubate for respiratory failure or anticipated respiratory failure.
  

• ABCs
  
• Intubation for impending airway failure:
  
  • Prepare for possible foreign body in airway.
    
  • Anticipate difficult airway.
    

• Correct hypoxemia: Supplemental oxygen
  
• Initial assessment of severity:
  
  • PEF >40%: Mild–moderate
    
  • PEF <40%: Severe
    
• Treat the underlying condition.
  
• Rapid reversal of airflow obstruction:
  
  • Bronchodilators:
    
    • Reversibility following the use of short-acting β-agonists such as albuterol or terbutaline suggests reactive airway disease.
      
  • Anticholinergics: Ipratropium bromide:
    
    • Add to β-agonist therapy for severe disease
      
• Reduce likelihood of relapse:
  
  • Trial of steroids indicated if wheezing is caused by bronchospasm or noninfectious inflammation.
    
• Adjunctive agents:
  
  • Heliox:
    
    • Less dense than air or oxygen alone
      
    • Decreases work of breathing
      
    • More efficacious in large-airway disease
      
    • Not as effective for small-airway disease
      
  • Magnesium sulfate:
    
    • Evidence for benefit only in moderate to severe asthmatics
      
  • Ketamine:
    
    • For intubation of the asthmatic patient
      

• Albuterol: 2.5–5 mg in 2.5 mL NS q20min inhaled × 3 doses (peds: 0.15 mg/kg/dose q20min × 3 doses; min. dose 2.5 mg)
  
• Levalbuterol: 0.63 mg q8h (peds: 6–12 yr 0.31 mg q8h; >812 yr 0.63 mg q8h) via nebulizer
  
• Prednisone: 40–80 mg PO (peds: 1 mg/kg/d in 2 div. doses; max. 60 mg/d)
  
• Prednisolone: Peds 1–2 mg/kg/d in 2 div. doses PO; ipratropium insert in peds dose (peds: >12 yr 0.25–0.5 mg)
  
• Racemic epinephrine: Peds 0.25–0.5 mL nebulized for croup
  

• Ipratropium bromide: 0.5 mg q20min × 3 doses (peds: 0.25–0.5 mg q20min × 3 doses); may mix with albuterol
  
• Methylprednisolone: 40–80 mg IV (peds: 1–2 mg/kg/d IV or PO in 2 div. doses, max. 60 mg/d) for patients who cannot tolerate PO
  
• Terbutaline: 0.25 mg SC q0.5h for 2 doses (peds: 0.01 mg/kg up to 0.3 mg SC):
  
  • No proven advantage over aerosol therapy
    
• Magnesium sulfate: 0.1 mL/kg of 50% solution IV over 20 min, then 0.06 mg/kg/h
  

FOLLOW-UP

• Hypoxia
  
• Persistent or worsening wheezing
  
• Underlying condition requires hospital admission
  

• Improvement or resolution of wheezing
  
• PEF >70% predicted
  
• Adequate oxygenation
  

Asthma:

• Referral should be made for a written asthma action plan.
  

The patient should be instructed to return to the ED with shortness of breath, fever, hemoptysis, or chest pain.

Be prepared to manage the airway if administering an anxiolytic.

• Bacharier LB. Evaluation of the child with recurrent wheezing.
  J Allergy Clin Immunol.
  2011;128(3):690.e1–e5.
  
• Fernandes RM, Bialy LM, Vandermeer B, et al. Glucocorticoids for acute viral bronchiolitis in infants and young children.
  Cochrane Database Syst Rev
  . 2013;6:CD004878.
  
• Krafczyk MA, Asplund CA. Exercise-induced bronchoconstriction: Diagnosis and management.
  Am Fam Physician
  . 2011;84(4):427–434.
  
• Mellis C. Respiratory noises: How useful are they clinically?
  Pediatr Clin North Am
  . 2009;56(1):1–17, ix.
  
• Weinberger M, Abu-Hasan M. Pseudo-asthma: When cough, wheezing, and dyspnea are not asthma.
  Pediatrics
  . 2007;120(4):855–864.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Asthma, Adult
  
• Asthma, Pediatric
  

CODES

• 493.90 Asthma, unspecified type, without mention of status asthmaticus
  
• 519.11 Acute bronchospasm
  
• 786.07 Wheezing
  

BASICS

• Alcohol withdrawal is the most common withdrawal syndrome encountered in the emergency department
  
• Neuroexcitation is the hallmark of alcohol withdrawal
  
• Alcohol withdrawal may be life threatening.
  
• More severe symptoms and signs are seen in patients with prior episodes of withdrawal, a process called kindling
  
• Alcoholism is not uncommon among older adults.
  
• Age-related increase in alcohol sensitivity
  
• Alcohol-related problems may be misdiagnosed as normal consequences of aging.