Stepwise Management of Status Asthmaticus Refractory to Initial Therapy: A Case Report

Asthma is one of the most prevalent chronic respiratory illnesses, significantly impacting patients through shortness of breath and even death. Acute exacerbations are usually controlled with a short-acting beta agonist, such as an albuterol inhaler, as well as long-acting agents to prevent the occurrence of exacerbations and status asthmaticus. Status asthmaticus is an emergent episode of asthma that is refractory to standard treatment. This disease presents as tachycardia, tachypnea, and dyspnea. The forced expiratory volume measures the severity of asthma in one second and the serial peak expiratory flow rate. Proper treatment is vital for patient survival. This case report reviews the proper treatment of a patient in her mid-30s presenting to the emergency department due to an asthmatic attack refractory to albuterol. The patient went through a five-stage treatment plan. First, the patient was treated with inhaled beta-2 agonist (albuterol) and corticosteroids (prednisone, dexamethasone, and methylprednisolone). The patient did not improve with these treatments and was given the anticholinergic agent ipratropium bromide in an attempt to increase bronchodilation. Nebulized racemic epinephrine was then added to the patient to optimize maximum bronchodilation and vasoconstriction in an attempt to reduce airway edema and inflammation. To reduce ventilator peak airway pressures through sedation and paralytics, rocuronium and cisatracurium (Nimbex) were administered. Ketamine was added as a sedative and bronchodilator. Propofol and midazolam (Versed) were used to sedate the patient for mechanical ventilation. After the acute episode, maintenance therapy included inhaled corticosteroids (budesonide), a long-acting beta-2 agonist (arformoterol), a long-acting muscarinic antagonist (revefenacin), and montelukast (a leukotriene receptor antagonist). This case illustrates the importance of status asthmaticus treatment as a vital, stepwise process that focuses on bronchodilation, maintaining the airway, mechanical ventilation, sedation, and reducing inflammation and paralysis.