In a 15‑year‑old with asthma who experienced a perfume‑triggered anaphylactoid reaction in the emergency department (no epinephrine administered and no chest radiograph performed) and now presents with pleuritic right mid‑back pain that worsens with deep inspiration, should an urgent chest radiograph be obtained to rule out pneumothorax or other thoracic pathology?

Urgent Chest X-Ray is Mandatory in This Patient

This 15-year-old with asthma presenting with pleuritic chest pain that worsens with deep inspiration requires an immediate chest radiograph to exclude pneumothorax, which is a recognized and potentially life-threatening complication of acute asthma exacerbations. 1

Critical Diagnostic Concerns

Pneumothorax Must Be Ruled Out

• The British Thoracic Society explicitly recommends chest radiography to exclude pneumothorax in patients with life-threatening features of acute asthma. 1
• This patient's pleuritic pain (sharp, mid-back pain radiating anteriorly along ribs, worse with deep breathing) is a classic presentation of pneumothorax, not muscle strain. 2
• Pneumothorax in asthmatic patients carries high morbidity and mortality, and delayed diagnosis while focusing only on bronchospasm is a well-documented pitfall. 2

The Initial ER Visit Was Suboptimal

• The patient experienced what sounds like a severe asthma exacerbation (throat closing, gasping for air, inability to breathe) but received no epinephrine and no chest imaging—both represent significant gaps in acute asthma management. 1
• The administration of a muscle relaxant for "upper back soreness" without imaging suggests the ER missed the pleuritic nature of this pain. 1
• True anaphylaxis (if that's what occurred with perfume exposure) requires epinephrine as first-line treatment, not just bronchodilators. 3, 4

Immediate Management Algorithm

Step 1: Obtain Chest X-Ray NOW

• Order a chest radiograph immediately to exclude pneumothorax, consolidation, or pulmonary edema before any other interventions. 1
• Do not wait for worsening symptoms—pleuritic chest pain in an asthmatic patient is pneumothorax until proven otherwise. 2

Step 2: Assess Current Asthma Severity

While awaiting imaging, evaluate for features of acute severe asthma: 1, 5

• Severe features: Cannot complete sentences in one breath, respiratory rate >25/min, pulse >110/min, peak expiratory flow <50% predicted, diminished breath sounds 1, 5
• Life-threatening features: Silent chest, cyanosis, oxygen saturation <92%, confusion, exhaustion, bradycardia, hypotension 1, 5

Step 3: Initiate Bronchodilator Therapy

• Give nebulized salbutamol 5 mg (or terbutaline 10 mg) via oxygen-driven nebulizer immediately. 1, 6
• Administer systemic corticosteroids: prednisolone 30-60 mg orally or hydrocortisone 200 mg IV. 1, 6, 7
• Provide 40-60% oxygen to maintain saturation >92%. 1, 6, 7

Step 4: Reassess at 15-30 Minutes

• Measure peak expiratory flow and clinical response 15-30 minutes after initial nebulizer treatment. 1, 6, 5
• If severe features persist, repeat nebulized bronchodilators and add ipratropium 0.5 mg. 1, 6

Critical Pitfalls to Avoid

Do Not Dismiss Pleuritic Pain as Musculoskeletal

• Pain that is sharp, radiates along dermatomes, and worsens specifically with deep inspiration is pleuritic, not muscular. 2
• Muscle relaxants have no role in acute asthma management and may mask serious pathology. 1
• The association between pneumothorax and asthma is underrecognized, leading to delayed diagnosis and increased mortality. 2

Do Not Assume This Was Simple Bronchospasm

• Perfume exposure can trigger true anaphylaxis with respiratory distress, urticaria, and airway compromise—not just asthma exacerbation. 4
• The patient's description of "throat closing" suggests laryngeal edema, which requires epinephrine, not just bronchodilators. 3, 4
• The absence of epinephrine administration in the ER represents a potential treatment failure if this was anaphylaxis. 3

Recognize When Hospital Admission is Required

Admit immediately if: 1, 5

• Any life-threatening features are present
• Severe asthma features persist after initial treatment
• Peak expiratory flow remains <50% predicted after 1-2 hours
• Chest X-ray reveals pneumothorax or other acute pathology

Follow-Up Recommendations

If Chest X-Ray is Normal

• Continue aggressive asthma management with nebulized bronchodilators every 4-6 hours. 1, 7
• Complete a 5-10 day course of oral corticosteroids. 6, 7
• Provide written asthma action plan and ensure adequate inhaled corticosteroid supply. 6, 5
• Arrange follow-up within 24 hours to reassess symptoms and optimize controller therapy. 6, 5

If Pneumothorax is Confirmed

• Immediate pulmonology or thoracic surgery consultation is required. 1
• Treatment depends on size: observation for small pneumothorax (<2 cm), needle aspiration or chest tube for larger pneumothorax. 2
• Admit for monitoring and continue asthma management concurrently. 7

Address the Anaphylaxis Component

• Prescribe an epinephrine auto-injector (EpiPen) for future episodes if this was true anaphylaxis. 3, 4
• Educate on strict avoidance of triggering perfumes/fragrances. 4
• Consider allergy/immunology referral for comprehensive evaluation. 4