Makindo Medical Notes

Related Subjects: Asthma |Acute Severe Asthma |Exacerbation COPD |Pulmonary Embolism |Cardiogenic Pulmonary Oedema |Pneumothorax |Tension Pneumothorax |Respiratory (Chest) infections Pneumonia |Fat embolism |Hyperventilation Syndrome |ARDS |Respiratory Failure |Diabetic Ketoacidosis

⚠️ Prevention is key: All patients at risk of severe exacerbations should have an individualised plan 📋 to manage deterioration early with short-acting beta-agonists (SABA), oral steroids, and clear instructions to seek urgent medical help.

Note: 💊 The fixed combination of an inhaled corticosteroid (ICS) and a LABA improves lung function, reduces exacerbations, and enhances quality of life in asthma.

📖 About

• Asthma is a chronic inflammatory disease with intermittent, reversible airway obstruction.
• 📈 Prevalence is rising, but better access to ICS has reduced hospitalisations.
• ⚠️ Acute severe asthma can deteriorate rapidly → patients should never be left unobserved.
• Symptoms: Wheeze, SOB, chest tightness, cough.

🧑‍⚕️ Basics of Initial Care

• 🪑 Sit patient upright, reassure, hydrate, encourage controlled breathing.
• 💙 Calm, competent staff presence reduces patient distress.
• 📊 Monitor continuously: ECG, SpO₂, frequent obs.
• 🚑 Never leave patients unattended, even for transfers.

📊 Assessing Severity

• 🔴 Acute Severe: SpO₂ >92%, PEF 33–50%, RR >25, HR >110, unable to speak full sentences.
• ⚫ Life-Threatening: PEF <33%, SpO₂ <92%, PaO₂ <8 kPa, silent chest, exhaustion, arrhythmias, hypotension, coma.
• ⚠️ Near-Fatal: Raised PaCO₂, requiring intubation/ventilation.
• ✅ Safe Discharge: Symptom-free, PEFR ≥75%, stable on ICS + oral steroids, written plan in place.

🩻 Chest X-ray Indications

• Not routine unless: suspected pneumothorax, consolidation, pneumomediastinum, life-threatening asthma, poor response, or need for ventilation.

🚑 Management if PEFR <50% + Signs of Acute Severe Asthma

• 🏥 Admit immediately, senior/ICU input within 15–20 min.
• 🫁 O₂ 15 L/min (target SpO₂ 92–94%).
• 💧 IV fluids (add K⁺ if needed – salbutamol lowers potassium).
• 💨 Nebulised Salbutamol 5 mg q15–20 min (or Terbutaline 5–10 mg).
• ➕ Ipratropium Bromide 500 mcg every 4–6 hrs.
• 💊 Prednisolone 40–60 mg PO or Hydrocortisone 200 mg IV stat, then 100 mg IV q6h.
• 🚫 Avoid unnecessary CXR/ABG unless severe/non-responding.

🌟 Management if PEFR >50% (No Severe Signs)

• 💨 10 puffs Salbutamol via spacer.
• 💊 Prednisolone 40 mg PO.
• Good Response: PEFR >75% after 1 hr → continue steroids x 5 days, ICS prescribed, safe discharge.
• Partial Response: PEFR <75% → consider nebulised bronchodilator, IV magnesium, admit if no further improvement.

🧪 Escalation in Non-Responders

• ⚡ IV Magnesium 1.2–2 g over 20 min.
• 💉 Aminophylline infusion (if not on theophylline) with ECG monitoring.
• 🚑 Adrenaline 0.5 mg IM if asthma triggered by anaphylaxis.
• 💉 IV Salbutamol infusion – monitor for lactic acidosis.
• Intubation Criteria: Arrest, exhaustion, drowsiness, PaO₂ <8 kPa on 60% O₂, PaCO₂ >6 kPa with acidosis → early ICU.

🏡 Discharge Planning

• 📖 Check inhaler technique + ensure ICS prescribed.
• 💊 Continue oral Prednisolone 5–10 days.
• 🚭 Smoking cessation advice.
• 🫁 Stop nebulisers 24h before discharge.
• 📋 Provide written asthma action plan + PEF meter.
• 📅 Arrange follow-up with GP/asthma nurse within 4 weeks.

📚 References

• GINA Guidelines 2019
• ERS/ATS Severe Asthma Guideline (2019)

3 Clinical Cases — Acute Severe Asthma (Status Asthmaticus) 🚨🫁

• Case 1 — Acute severe attack 🛑: A 26-year-old woman with known asthma presents with acute breathlessness after a viral upper respiratory infection. She is tachypnoeic, speaking in short phrases, RR 32/min, HR 120 bpm, SpO₂ 89% on air, PEFR 180 L/min (40% predicted). Teaching: This meets BTS criteria for acute severe asthma. Immediate treatment = high-flow O₂, nebulised salbutamol + ipratropium, IV steroids, close monitoring.
• Case 2 — Life-threatening features ⚡: A 32-year-old man arrives in A&E with exhaustion and a silent chest on auscultation. SpO₂ 84% on air, HR 140 bpm, BP 88/50 mmHg. ABG: PaO₂ 6.5 kPa, PaCO₂ 7.2 kPa, pH 7.20. Teaching: Features = silent chest, hypotension, exhaustion, hypercapnia → life-threatening asthma. Requires urgent ICU referral, IV magnesium sulphate, consideration of IV aminophylline, and possible intubation/ventilation.
• Case 3 — Near-fatal asthma 💔: A 29-year-old woman collapses at home after worsening breathlessness despite repeated salbutamol inhalers. On arrival: unresponsive, SpO₂ 72%, pulseless electrical activity arrest. ROSC achieved after advanced life support. Teaching: Near-fatal asthma