Asthma — SAQ

Stem

A 24-year-old woman with known asthma presents with 6 hours of progressive wheeze and breathlessness after a viral prodrome. She cannot complete sentences in one breath. Respiratory rate is 32/min, heart rate 124/min, SpO2 91% on air, and PEF is 40% of her best. She is using accessory muscles. There is widespread expiratory wheeze. She has had two previous ICU admissions for asthma.

Questions

a) Grade the severity of this acute attack and list the features that define life-threatening asthma. (3 marks)

This is acute severe asthma (RR ≥25, HR ≥110, cannot complete sentences, PEF 33–50% best). (1 mark)

Life-threatening features (any of — 2 marks for ≥4 correctly named): PEF <33% best/predicted; SpO2 <92%; silent chest; cyanosis; poor respiratory effort; arrhythmia; hypotension; exhaustion; altered consciousness; normal or raised PaCO2.

b) Outline immediate management in the first hour with drugs, doses, and routes. (4 marks)

• Controlled high-concentration oxygen to target SpO2 93–95% (0.5)
• Salbutamol 5 mg nebulised (oxygen-driven), repeated every 15–20 min or continuous (1)
• Ipratropium bromide 500 mcg nebulised with salbutamol (0.5)
• Prednisolone 40–50 mg oral immediately OR hydrocortisone 100 mg IV if cannot take oral (1)
• IV magnesium sulphate 1.2–2 g over 20 minutes if acute severe with poor response (0.5)
• Continuous monitoring; ABG if life-threatening features; senior/ICU review early given prior ICU asthma (0.5)

c) What discharge criteria and follow-up steps would you use once she improves? (3 marks)

Any three well-explained (1 each, max 3): PEF >75% best and stable on 3–4-hourly bronchodilators; SpO2 normal on air; written personalised asthma action plan; complete 5-day oral steroid course; check inhaler technique and adherence; step-up maintenance therapy (ICS-containing regimen; consider MART); early GP/respiratory follow-up within 48 hours if recent severe attack; trigger review; specialist referral given prior near-fatal/ICU asthma.