What is the appropriate initial management for a patient presenting with wheezing, respiratory distress, and elevated white blood cell count, with no known history of allergies?

Initial Management of Acute Respiratory Distress with Wheezing and Elevated WBC Count

The appropriate initial management for a patient presenting with wheezing, respiratory distress, and elevated white blood cell count with no known history of allergies should include immediate administration of high-flow oxygen, nebulized salbutamol 5 mg (or terbutaline 10 mg), and systemic corticosteroids (prednisolone 30-60 mg orally or hydrocortisone 200 mg intravenously). 1

Assessment of Severity

First, rapidly assess the severity of the respiratory distress:

Features of Severe Asthma/Respiratory Distress:

• Too breathless to complete sentences in one breath 1
• Respiratory rate >25 breaths/min (adults) or >50 breaths/min (children) 1
• Heart rate >110 beats/min (adults) or >140 beats/min (children) 1
• Peak expiratory flow (PEF) <50% of predicted normal or best 1

Life-Threatening Features:

• PEF <33% of predicted normal or best 1
• Silent chest, cyanosis, or feeble respiratory effort 1
• Bradycardia or hypotension 1
• Exhaustion, confusion, or coma 1

Immediate Management Algorithm

Step 1: Initial Treatment

• Administer high-flow oxygen (40-60%) via face mask 1
• Give nebulized β-agonist: salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer 1, 2
• Administer systemic corticosteroids: prednisolone 30-60 mg orally or hydrocortisone 200 mg intravenously 1, 3

Step 2: If Life-Threatening Features Present, Add:

• Ipratropium 0.5 mg nebulized (add to the β-agonist nebulizer) 1
• Consider intravenous aminophylline (250 mg over 20 minutes) or intravenous salbutamol/terbutaline (250 μg over 10 minutes) 1
• Note: Do not give bolus aminophylline to patients already taking oral theophyllines 1

Step 3: Monitor Response (15-30 minutes after initial treatment)

• Repeat measurement of PEF 1

• Monitor oxygen saturation (maintain SaO₂ >92%) 1

• If patient is improving:

  • Continue oxygen therapy 1
  • Continue prednisolone/hydrocortisone 1
  • Continue nebulized β-agonist every 4-6 hours 1

• If patient is NOT improving after 15-30 minutes:

  • Continue oxygen and steroids 1
  • Give nebulized β-agonist more frequently (every 15-30 minutes) 1
  • Add ipratropium 0.5 mg to nebulizer and repeat every 6 hours until improvement 1

Special Considerations for Elevated WBC Count

The elevated white blood cell count requires careful consideration:

• While high WBC counts can suggest bacterial infection, this finding alone is not sufficient to distinguish between viral and bacterial etiologies in respiratory distress 4
• High specificity (95%) for bacterial infection is seen with WBC counts >20.0 x 10⁹/L 4
• Consider obtaining blood cultures and initiating empiric antibiotics if bacterial infection is suspected, particularly with very high WBC counts 4, 5
• Note that transient changes in WBC count can also occur with acute respiratory distress syndrome (ARDS) 6

Criteria for Hospital Admission

Admit the patient if any of the following are present:

• Any life-threatening features 1
• Any features of severe respiratory distress persisting after initial treatment 1
• PEF <33% of predicted or best after initial treatment 1
• Social factors that might impede management 1

Criteria for ICU Transfer

Transfer to ICU with a doctor prepared to intubate if:

• Deteriorating PEF 1
• Worsening or persistent hypoxia despite oxygen therapy 1
• Exhaustion, confusion, drowsiness 1
• Coma or respiratory arrest 1

Important Cautions

• Paradoxical bronchospasm can occur with β-agonists and may be life-threatening; discontinue immediately if this occurs 7, 8
• Deterioration of asthma may occur over hours; increased need for β-agonists may indicate destabilization requiring re-evaluation 7
• Deaths from asthma are often associated with underestimation of severity and underuse of corticosteroids 1
• No sedatives should be given to patients with acute respiratory distress 1
• Consider chest radiograph to exclude pneumothorax or other complications 1