Patient A reports allergies to erythromycin and penicillin. She has a history of asthma precipitated by dust, pollens, fumes, and air pollution requiring multiple emergency department visits and hospital admissions over the past 10 years. She also reports thrombophlebitis and hypertensive syncope accompanied by seizure activity for one year.

Past surgical procedures include left brachial artery embolectomy done 4 years previously, right knee repair completed 10 years previously, remote hemorrhoidectomy, and remote tonsillectomy and adenoidectomy in childhood. She is currently taking sustained-release theophylline, prednisone, phenytoin, warfarin, terbutaline sulfate, and metaproterenol sulfate inhaler.

Upon admittance to the CCU, a full physical exam is conducted (Table 1). An ECG is done and shows sinus tachycardia with incomplete right bundle branch block. Several laboratory tests are ordered, with the following results:

Based on the results of the assessment, Patient A is diagnosed with acute asthma attack.

Patient A's ventilation and oxygenation are managed and monitored by arterial blood gas results. Pulmonary spirometry is also used to evaluate her progress, and there is marked improvement with a bronchodilator. Patient A is transferred out of the CCU on the fourth day and discharged on the seventh day.

Patient B has a history of spring "hay fever" and rare asthma since puberty. For the past 18 years, he has had progressive emphysema with a reversible component. Two years previously, he was diagnosed with adenocarcinoma of the lung. He also reports an allergy to penicillin.

At 12 years of age, Patient B underwent right inguinal herniorrhaphy. Sixteen years ago, he underwent gastrojejunal anastomosis, followed by right upper lobotomy requiring tracheotomy, and right upper lobotomy for benign organized pneumonitic process. Nine years previously, an appendectomy and repair of perforated sigmoid disarticulates with peritonitis were performed.

Upon admittance to the CCU, a full physical exam is conducted (Table 2). Complete blood count, electrolytes, and urinalysis are all within normal limits.

Based on the results of the assessment, Patient B is diagnosed with:

Patient B is given aerosolized bronchodilators every one to two hours initially. An aminophylline infusion is administered as well. The frequency of the aerosol treatments is gradually reduced to every four hours, with supplemental oxygen administered by nasal cannula. Patient B's ventilation and oxygenation are managed and monitored by arterial blood gas results (Table 3).

The nurses work with a dietitian to provide small, frequent, high-calorie and high-protein meals. This approach, adapted to his anorexia, dyspnea, and previous gastric surgery, improves Patient B's nutritional status. Patient B is transferred out of the CCU on the second hospital day and discharged five days after admission.

One month after discharge, Patient B is readmitted in acute respiratory failure. He and his family decide no resuscitation should be performed, and he dies two days after readmission.