Breathlessness-2 (Acute asthma attack)

A 30-year-old patient with poorly controlled asthma under the respiratory team has been admitted to the ED with worsening SOB and cough with expectoration. You have been asked to review her in ED as she has become more unwell.

Answer:

I would start by getting a focused history if the patient is able to give a brief history and ask about the speed of onset of symptoms and other associated respiratory symptoms such as cough, sputum, chest pain, and difficulty lying flat. I would also ask about significant past medical history of cardiorespiratory problems, how well controlled her asthma was, and inquire about significant risk factors, such as smoking history, exposure to pets, mould, and a history of exposure to unwell contacts. After this, I would proceed with a focused assessment using the A to E approach.

Airway: I would ensure the airway is patent and if necessary insert an airway adjunct such as OP or NP airway. If the patient is tolerating an airway adjunct, I would be really worried and seek the help of the critical care team after my assessment.

Breathing: I would look at the observations, specifically the oxygen saturation and the respiratory rate. If the patient is hypoxic or has increased work of breathing, I’ll start the patient on supplemental oxygen therapy. I would also get a PEFR (Peak Expiratory Flow Rate) and an ABG (Arterial Blood Gas) done for this patient to assess the pH, pO2, pCO2, HCO3, and lactate levels. I would be very concerned if the pCO2 was normal or rising. I would also arrange a portable CXR (Chest X-ray) for the patient.

Circulation: I would look at the observations, specifically the BP, heart rate, and CRT (Capillary Refill Time). If there is evidence of hypotension or tachycardia, I would give a fluid challenge to see if there is an adequate response. If the patient remains hypotensive despite the first fluid challenge, I would give another fluid challenge and ensure the critical care team is aware of the patient. I would also ensure the patient has a working cannula and send basic bloods, including septic screening. I would also request an ECG for the patient.

Disability: I would check the patient’s blood glucose, temperature, and perform a focused neurological assessment that includes GCS. Specifically, if the GCS is less than 8 or if there are focal neurological deficits, I would be concerned and investigate this further.

Question – At this point, interrupt the candidate and give the following findings:

The patient has evidence of increased respiratory rate (30/min), PEFR <50%, and she is unable to complete sentences. She has bilateral wheeze on examination. Her ABG shows pH 7.3, pO2 8.0, pCO2 4.0, HCO3 24, lactate 2.0. What would you do next?

Answer:

Based on the findings, the patient has symptoms and signs of severe asthma. I would sit her up and give 15L/min O2. I will start Salbutamol 5mg nebulized ± ipratropium 500mcg nebulized and prednisolone 40mg PO (or hydrocortisone 200mg IV). I would drive the nebulizer mask from the O2 supply, not air, and repeat salbutamol 2.5mg nebulized every 10–15 minutes while reassessing PEFR and oxygen saturation frequently. I would also start antibiotics if there is evidence of infection.

I would ensure my seniors are aware of the patient and nurse the patient in the high observation area.

Question – The patient continues to deteriorate, and her SpO2 is <92% on supplemental oxygen, her pO2 is <8, and she has poor respiratory effort. What would you do now?

Answer:

This patient has life-threatening asthma, and given the rapid deterioration, I would immediately repeat the ABG, get the critical care team involved, and consider administering IV magnesium sulfate 2 grams IV over 20 minutes and/or an IV aminophylline infusion at 0.5–0.7mg/kg/hr.

I would also ensure I request my seniors to review this patient and update the family on the clinical status.