What is the best course of treatment for a patient with a reactive airway (asthma-like symptoms) after vomiting, with stable oxygen saturation (oxygen sats) but significant concern for swelling and potential airway compromise?

Management of Reactive Airway After Vomiting with Concern for Swelling

Given the major concern for airway swelling in this patient with reactive airway symptoms after vomiting, you should immediately administer IV hydrocortisone 200 mg, high-dose nebulized β-agonists (albuterol 5 mg), and prepare for potential early intubation while closely monitoring for signs of deteriorating airway patency. 1

Immediate Pharmacological Management

Administer IV corticosteroids immediately - the vomiting precludes oral medication and indicates severity requiring parenteral therapy:

• Hydrocortisone 200 mg IV every 6 hours (preferred over oral prednisolone given the vomiting) 1, 2
• Corticosteroids require 6-12 hours to manifest anti-inflammatory effects, making early administration critical 1

Initiate aggressive bronchodilator therapy:

• Nebulized albuterol 5 mg driven by oxygen 1, 3, 4
• Can be repeated every 15 minutes if not improving 1
• If inadequate response, consider continuous nebulization 1

Aminophylline if bronchospasm is severe and not responding to β-agonists 2

Critical Airway Assessment and Monitoring

The combination of vomiting, reactive airway, and swelling concern creates high risk for airway compromise. You must actively monitor for:

• Signs requiring urgent intubation: dyspnea, desaturation, stridor, inability to complete sentences, respiratory rate >25/min 5, 3
• Peak expiratory flow before treatment and 15-30 minutes after to assess response 1, 3
• Oxygen saturation continuously - though currently maintaining, this can deteriorate rapidly 3
• Warning signs of worsening: agitation, obstructed breathing pattern, increasing work of breathing 5

Decision Point: Early vs. Conservative Airway Management

The decision to intubate early (to prevent deterioration) versus manage conservatively is complex and requires a senior decision-maker 5. However, given your stated major concern for swelling:

Consider early intubation if:

• Peak flow <33% predicted after initial nebulization 1
• Any signs of stridor or upper airway obstruction develop 5
• Progressive swelling is observed 5
• Patient seen in afternoon/evening or has history of severe attacks 1

If managing conservatively:

• Observe in high-dependency area 5
• Nurse head-up position 5
• Keep nil-by-mouth 5
• Reassess frequently to detect deterioration early 5

Critical Pitfall: Fluid Management

Avoid large volume fluid resuscitation as this will worsen airway swelling 5. This is particularly important in your patient where swelling is already a major concern.

Intubation Technique if Required

If intubation becomes necessary, use modified rapid sequence intubation (RSI):

• Have a low threshold for videolaryngoscopy 5
• Use an uncut tracheal tube to allow for subsequent facial/airway swelling 5
• Consider awake intubation only if patient is cooperative and stable 5
• Have front-of-neck access (FONA) equipment immediately available 5

Absolute Contraindications

Never administer sedatives - they are absolutely contraindicated in asthmatic patients and can worsen respiratory depression 1, 3, 6

Do not give antibiotics unless bacterial infection is clearly documented 1, 3, 6

Additional Monitoring

• Chest radiography to exclude pneumothorax, consolidation, or pulmonary edema 1, 6
• Plasma electrolytes and urea as vomiting can cause disturbances 1, 6
• Arterial blood gases if severe or not responding 3

Disposition

This patient requires hospital admission given:

• Vomiting during asthma flare lowers threshold for admission 1
• Major concern for swelling indicates high-risk airway 5
• Need for intensive monitoring and potential airway intervention 1