Asthmatic Child with Fever and Respiratory Distress: A Case Analysis

QUESTION

Chief Complaint
“My daughter has had a bad fever, and now she is having trouble breathing, and albuterol doesn’t help.”

HPI

An 8-year-old African-American girl who presents to the ED with a 2-day history of fevers, malaise, and nonproductive cough. The mother gave acetaminophen and ibuprofen to help control the fever. Mother stated that “a lot of other kids in her class have been sick this fall, too.” The patient started having trouble breathing the morning of admission, and the mother gave her albuterol, 2.5 mg via nebulization twice within an hour. The patient still sounded wheezy to the mother after the albuterol, and the patient stated it was “hard to breath.”

The patient was previously well controlled regarding asthma symptoms. Previous clinic notes reported symptoms during the day only with active play at school or at home and rare nighttime symptoms. She uses PRN albuterol to help with symptoms after playing.

Her assessment in the emergency department revealed the patient to have labored breathing, such that she could only complete four- to five-word sentences. She had subcostal retractions, tracheal tugging with tachypnea at 54 breaths/min. Her other vital signs were a heart rate of 160 bpm, blood pressure of 115/59, temperature of 38.8°C, and a weight of 22.7 kg. The initial oxygen saturation was 88%, and she was started on oxygen at 1 L/min via nasal cannula. Bilateral expiratory and inspiratory wheezes were noted on examination. A chest x-ray revealed a right lower lobe consolidation consistent with pneumonia and possible effusion.

PMHx

Asthma, last hospitalization 4 years ago, and has had two courses of oral corticosteroids in the past year

PSHx

Denied

Medications

Albuterol 2.5 mg nebulized Q 4-6 H PRN wheezing Fluticasone propionate 44 mcg MDI two puffs BID Acetaminophen 160 mg/5 mL—10 mL Q 4 H PRN Ibuprofen 100 mg/5 mL—10 mL Q 6 H PRN

Allergies

ANSWER

Asthmatic Child with Fever and Respiratory Distress: A Case Analysis

Introduction

This case analysis focuses on an 8-year-old African-American girl who presents to the emergency department (ED) with a chief complaint of fever and trouble breathing. The patient has a previous diagnosis of asthma and is experiencing worsening respiratory symptoms. This essay will discuss the patient’s history, physical examination findings, and medication regimen. Additionally, it will explore the potential cause of the symptoms and consider appropriate management strategies for this asthmatic child.

Patient History

The patient’s history reveals a 2-day onset of fevers, malaise, and nonproductive cough. The mother reports that other children in the patient’s class have also been ill recently. The patient’s asthma symptoms were previously well controlled, with occasional daytime symptoms during physical activity and rare nighttime symptoms. PRN albuterol was used to manage symptoms after exertion.

Physical Examination Findings

The patient’s assessment in the ED revealed labored breathing, subcostal retractions, and tracheal tugging. Tachypnea was noted at 54 breaths per minute, and the patient could only complete short sentences. Wheezing was heard on auscultation, and the initial oxygen saturation was 88%. A chest x-ray revealed a right lower lobe consolidation consistent with pneumonia and possible effusion.

Medication Regimen

The patient’s current medication regimen includes PRN nebulized albuterol, fluticasone propionate inhaler, and PRN acetaminophen and ibuprofen for fever control.

Analysis and Management

Based on the clinical presentation, it is evident that the patient’s asthma symptoms have worsened and are accompanied by respiratory distress. The possible cause of the symptoms could be pneumonia, as indicated by the chest x-ray findings. This respiratory infection may have triggered an exacerbation of the patient’s asthma.

Management strategies for this asthmatic child should focus on addressing both the underlying pneumonia and the acute exacerbation of asthma. The following interventions may be considered:

Antibiotic Therapy: Administer appropriate antibiotics to target the suspected bacterial pneumonia and address the infection.

Bronchodilator Therapy: Continue PRN albuterol to relieve bronchospasm and improve airflow. If the patient’s symptoms do not improve, consider frequent nebulized albuterol or continuous albuterol therapy.

Systemic Corticosteroids: Administer systemic corticosteroids, such as oral prednisolone, to reduce airway inflammation and help control the acute asthma exacerbation.

Oxygen Therapy: Provide supplemental oxygen to maintain oxygen saturation above 92% and alleviate hypoxia.

Supportive Care: Encourage adequate hydration, rest, and symptomatic relief with PRN acetaminophen or ibuprofen for fever control.

It is important to closely monitor the patient’s response to treatment, including improvement in respiratory distress, resolution of fever, and normalization of oxygen saturation. Regular assessment of lung sounds, respiratory rate, and other vital signs is crucial for evaluating the effectiveness of the interventions.

Conclusion

This case analysis highlights the challenging clinical scenario of an asthmatic child presenting with fever and respiratory distress. Prompt recognition of the potential underlying cause, such as pneumonia, and appropriate management strategies are essential for achieving optimal outcomes. Close collaboration between the healthcare team, including pediatricians, respiratory therapists, and nurses, is vital to provide comprehensive care and ensure a favorable prognosis for the patient.