Makindo Medical Notes

The aim of treatment is to relieve airflow obstruction and prevent future relapses. Early treatment is most advantageous.

It would be wise to commence the beta-agonist Salbutamol via nebulisers which can be given back-to-back initially.

In this situation this is often given with the anticholinergic Ipratropium Bromide.

• 2.5-5mg Salbutamol at 15-30 min intervals
• 0.5mg Ipratropium bromide stat and then 4-6 hourly
  

  Should the Nebulisers be driven by room air.

  See Answer

  Absolutely not, his nebulisers should be connected to and driven by high flow oxygen to maintain saturations of 94-98%.

  The exception is the patient with advanced COPD which is very different picture nebulisers often connected to room air.
  

  Are there any other medications that may be appropriate

  See Answer

  He should be commenced on Systemic steroids. This is a key medication. In this situation, this is most easily done by giving Hydrocortisone 200 mg slow IV. Give it slowly as it can cause some quite extreme tingling!

  The patient may also be given Oral Steroids e.g. Prednisolone 30-40 mg stat and a course initiated. The patient may be too tired or distracted to drink and some IV fluids can be helpful.
  

  You request a CXR - are there any precautions

  See Answer

  The porters come to take the patient on oxygen and drip to the Radiology department next door. It is vitally important that asthmatic patients with moderate or severe asthma are accompanied at all times. Asthmatics can suddenly get better and suddenly get worse and sustain a cardiac/respiratory arrest.

  A CXR rarely alters management in acute severe asthma. A portable CXR in resus is enough and is only needed where there are concerns of failure to respond to treatment, clinical deterioration and need for ITU, suspected pneumothorax, surgical emphysema, suspected consolidation or other lung pathology. In practice, almost all admitted patients will get a CXR.

  The patient has failed to respond and looks tired. What may you consider now

  See Answer

  It is hard work for the asthmatic patient with tight airways and airflow obstruction to maintain that effort. The patient can become fatigued with tiring respiratory muscles.

  It would be reasonable to give IV Magnesium get senior EM help and to talk to the Critical care outreach team and ITU Registrar or Consultant.

  You prescribe Magnesium sulphate 2g IV infusion over 20 minutes

  Others may prefer then giving either IV Aminophylline and if the patient is not taking it orally then a loading dose is given.

  Other choices are IV Salbutamol infusions. This can cause a lactic acidosis. All of these agents can cause arrhythmias.

  It is at this point one should be considering HDU and need for intubation and ventilation if deteriorates.

  List some Indication for ITU

  See Answer

  • Deteriorating PEFR but often difficult to do as too breathless
  • Persisting or worsening hypoxia: You titrated down the FI)2 and now you need to increase it again to get sats 94-98%
  • Hypercapnia - suggests hypoventilating and tiring
  • Fall in pH in ABG
  • Exhaustion
  • Reduced GCS

    He agrees to an arterial blood gas. The PCO₂ is normal but elevated

    See Answer

    In asthma with a breathless patient the PCO₂ should in fact be low. This suggests tiring and impending respiratory difficulties. Get ITU help. Ensure high flow oxygen and Sats 94-98%.

    Consider an additional agent such as IV Salbutamol whilst help arrives. A MET call would be appropriate to get help.

    What complications are seen with Acute Severe Asthma

    See Answer

    Patients may have an infection such as pneumonia or develop a Hospital or Ventilator-associated pneumonia if he goes to ITU

    Lobar collapse may be due to mucus plugging. May require Bronchoscopy

    Pneumothorax may be seen and if present on CXR will need chest drain insertion

    Respiratory failure - Oxygen < 8KPA may be seen and these patients need high flow oxygen and bronchodilators, steroids, magnesium and urgent ITU review for Intubation

    Cardiac arrest due to hypoxia, arrhythmias, fatigue

    Side effects from treatment: hypokalaemia, arrhythmias

    Can you list 11 findings in Acute Severe Asthma.

    See Answer

    Any of these make the diagnosis of acute severe asthma

    • PEFR 33–50% best or predicted
    • Respiratory rate of at least 25/min
    • Pulse rate of at least 110/min
    • Inability to complete sentences in one breath
    • Oxygen saturation of at least 92%.
    • Exhaustion
    • Arrhythmias
    • Cyanosis
    • Silent chest
    • Poor respiratory effort
    • PAO₂ < 8KPA
    • Normal PCO₂ 4.6-6 Kpa

      Can you list findings in Near Fatal Asthma.

      See Answer
      • PEFR < 33% best or predicted
      • PaCO₂ > 6 Kpa

      References

      • NICE Asthma

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