Chest
Volume 138, Issue 5, November 2010, Pages 1253-1255
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Postgraduate Education Corner
Pulmonary and Critical Care Pearls
A 20-Year-Old Woman With Severe Asthma Refractory to Primatene Mist

https://doi.org/10.1378/chest.10-0684Get rights and content

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Physical Examination

She was afebrile with a pulse rate of 110 beats/min, a BP of 130/88 mm Hg, a respiratory rate of 24 breaths/min, and oxygen saturation on room air at 96%. Chest examination revealed symmetrical expansion and bilateral, diffuse, expiratory wheezes. The remainder of the examination was unremarkable.

Laboratory Findings

Initial CBC count revealed a WBC count of 9.6×103 cells/μL with 32% neutrophils, 29% lymphocytes, 9% monocytes, and 29% eosinophils. Serum chemistries were within normal limits. A chest radiograph revealed hyperinflation without infiltrates.

Initial Hospital Care

During the first 2 h after presentation the patient became increasingly tachypneic, with respirations reaching 30 breaths/min. She was placed on 2 L of oxygen by nasal cannula, received seven albuterol/ipratropium breathing treatments in the ED, received several doses of IV methylprednisolone (one dose of 40 mg and two doses at 125 mg), and received levofloxacin IV 750 mg. The patient was subsequently transferred to the ICU. Her heart rate increased to 136 beats/min, and she required additional

What is the cause of the acidosis?

What is the next step in treatment of this patient?

Cause: Metabolic acidosis secondary to β-agonist therapy

Next step: Stop albuterol treatment

Initial Hospital Care

After the initial blood gas analysis, albuterol inhalation was discontinued, and 0.5 mg ipratropium bromide was continued every 4 h by nebulizer. Methylprednisolone was changed to 40 mg every 6 h. The laboratory did not complete a request for lactate acid level and did not inform the clinicians about this technical problem. The patient steadily improved and reported less dyspnea and improved sleep quality. Serial vital signs confirmed the improving clinical status, with a heart rate of 81

Acknowledgments

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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