From the Guidelines
The patient should be started on albuterol nebulizer treatments (2.5mg every 4-6 hours as needed) for bronchospasm if present, and immediate diabetes management should be initiated given the elevated glucose of 297 mg/dL and A1C of 8.7%. The chest X-ray findings suggest mild vascular congestion or possibly bronchitis, requiring management of both respiratory symptoms and underlying diabetes. According to the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1, the patient's symptoms and signs do not indicate acute heart failure, as the BNP is <10 and there are no signs of significant congestion or hypoperfusion.
The normal troponin, D-dimer, and BNP values rule out acute cardiac issues and pulmonary embolism 1. The patient's glucose level of 297 mg/dL and A1C of 8.7% indicate poorly controlled diabetes, which should be addressed with insulin therapy, such as basal insulin (e.g., insulin glargine 10 units at bedtime) and rapid-acting insulin (e.g., insulin lispro 4 units before meals), while monitoring blood glucose levels every 4-6 hours. Oral metformin 500mg twice daily could be initiated if not contraindicated by kidney function.
The patient should be rehydrated with IV fluids (normal saline at 100-125 mL/hour) while monitoring for fluid overload given the vascular congestion on imaging. It is essential to correlate the patient's volume status with the chest X-ray findings, as recommended by the guidelines 1. Follow-up should include outpatient diabetes education, medication adjustment, and a repeat chest X-ray in 2-4 weeks to ensure resolution of the vascular congestion or bronchitis. This approach addresses both the acute respiratory findings and the poorly controlled diabetes that likely contributes to the patient's current condition.
From the Research
Patient Assessment
- The patient's chest x-ray shows mild vascular congestion versus the peribronchial thickening of lower airway disease, such as bronchitis, with no pleural effusion or pneumothorax.
- The patient's laboratory results include a troponin level of 0.01, D-dimer of 0.27, glucose of 297, creatinine of 0.69, BNP <10, and A1C of 8.7.
Hyperglycemia Management
- According to the study by 2, hyperglycemia is a significant factor in increasing the risk of extended hospitalization time due to asthma exacerbation, regardless of the method of insulin therapy.
- The study by 3 found that controlling glycemia at 4.5-7.2 mmol/l resulted in a shorter average hospitalization time compared to controlling glycemia at 7.2-10.0 mmol/l.
- The management of hyperglycemia in hospitalized adult patients in non-critical care settings is outlined in the guideline by 2, which includes conditional recommendations for hospital use of emerging diabetes technologies, insulin regimens, and noninsulin therapies.
Treatment Considerations
- The study by 4 found that nebulized albuterol causes no clinically significant increases in blood glucose in patients with diabetes mellitus or cystic fibrosis-related diabetes.
- The consensus report by 5 emphasizes the importance of weight management and social determinants of health in the management of hyperglycemia in type 2 diabetes.
- The patient's treatment at the ED should consider their hyperglycemia, with a focus on controlling their blood glucose levels and managing their asthma exacerbation.
Further Evaluation
- The patient's glucose level of 297 and A1C of 8.7 indicate poor glucose control, which should be addressed in their treatment plan.
- The study by 2 recommends a multidisciplinary approach to glycemic management in the hospital, including the use of insulin regimens and noninsulin therapies.
- The patient's treatment plan should be individualized based on their specific needs and medical history, with consideration of the latest guidelines and research on hyperglycemia management.