Acute Asthma Attack Flashcards
You are the IMT1 covering the acute medical unit. The nurse has called you to come and review James, a 19-year-old male patient who has been admitted with an exacerbation of their asthma. They were seen in A+E, transferred straight to the ward, and have not yet been seen by the medical team. You have been asked to see them. The nurse tells you they are having some difficulty breathing. They have had asthma as a childhood, but have never before been hospitalised due to asthma, and have no other significant past medical history.
What other diagnoses would you consider on your way to seeing this patient?
- Pneumonia
- Pneumothorax
- Anaphylaxis
- Heart failure
What do you need to consider when assessing someonea dmitted with an acute asthma attack?
When assessing a pt with an exacerbation of asthma, you must identify the severity of the asthma attack (as per BST)
Moderate acute asthma
Moderate
* Increasing symptoms
* PEF > 50-75% of predicted
* No features of acute severe asthma
Severe acute asthma
Severe
* Peak flow 33-50%
* RR ≥ 25
* HR ≥ 110
* Inability to complete sentences in one breath
Life-threatening acute asthma
Life-threatening
* Peak flow <33%
* SpO2 < 92% on RA
* PaO2 < 8 kPA
* Normal PaCO2
* Silent chest
* Poor respiratory effort, exhaustion
* Hypotension, arrhythmia, altered conscious level
Near-fatal acute asthma
Near-fatal acute asthma
* Raised PaCO2 and/or the need for mechanical ventialtion with raised inflation pressures
How would you assess a patient with an acute asthma attack and what beside tests would you perform to help determine the asthma attack’s severity?
Acute Asthma Attack Assessment (A-E Approach)
A – Airway:
- Assess for obstruction (stridor, wheeze).
B – Breathing:
- Check SpO₂, RR, respiratory distress (cyanosis, silent chest, poor effort).
- Listen for wheeze/crackles/reduced air entry.
- Tests: ABG, PEF (% of previous best/predicted).
C – Circulation:
- BP, HR (hypotension, tachycardia – life-threatening signs).
- IV access, blood tests (FBC, U&E, coagulation, D-dimer if indicated).
- CRT, hydration, heart auscultation, consider IV fluids, ECG.
D – Disability:
- Check blood glucose, GCS if drowsy/confused.
E – Exposure:
- Full examination for alternative causes.
- Key concern: Fatigue = escalate early for senior/anaesthetics support.
Key Bedside Tests:
- PEF: % of previous best or predicted.
- ABG: Oxygenation assessment.
- CXR: Rule out pneumothorax, pneumomediastinum, consolidation, or non-response to treatment.
- CTPA: If PE suspected.
The pt has the following observations: SpO2 91% on room air, respiratory rate 26, heart rate 127 bpm, temperature 36.9, and a BP of 110/78. In addition, his peak flow is 30% of predicted. How would you manage a life-threatening asthma attack?
Life-Threatening Asthma Management (Key Steps)
Immediate Action:
- Administer supplemental oxygen via non-rebreather mask to maintain SpO₂ 94-98%.
First-Line Treatment:
- Nebulised β₂ agonist (e.g., salbutamol) via oxygen-driven nebuliser.
- If limited response: Repeat back-to-back nebulisation.
Steroids:
- Administer corticosteroids to all exacerbations:
- Oral prednisolone (if tolerated)
- If not, consider IV hydrocortisone or IM methylprednisolone.
Adjunct Treatments:
- Nebulised ipratropium bromide (add if poor response to β₂ agonist).
- Consider IV magnesium sulfate for severe cases, after discussing with seniors.
Escalation:
- Continuous monitoring (SpO₂, RR, HR, PEF).
- Escalate early to senior/critical care if no improvement or signs of fatigue.
- Prepare for possible intubation/ICU transfer.
Ongoing Management:
- Repeat ABG and PEF regularly.
- Reassess response to treatment and adjust accordingly.
IV Magnesium Sulphate is bronchodilatory and has **anti-inflammatory
Do you know any criteria that would prompt you to discuss this patient with ITU?
- Requiring ventiulatory support
- Acute severe or life-threatening asthma, who is failing to respond to therapy, as evidenced by
- deteriorating PEF
- persisting/worsening hypoxia
- hypercapnia
- ABG showing decreasing pH
- exhaustion
- drowsiness, confusion, altered conscious state
- respiratory arrest
You have started treatment with the patient but they collpase whilst you are on the ward. What would you do?
- I would immediately put out a ‘2222’ adult cardiac arrest call
- Call for help in the ward
- Immediate assessment as per the ALS guidelines and start the CPR
Key management steps in cardiac arrest in a patient with acute asthma
- Continue administer high flow oxygen – hypoxaemia is likely the cause of the arrest
- Ventilate with respiratory rate (8-10 min) and sufficient tidal volume to cause the chest to rise
- Aim to intubate early once your anaesthetic team arrive
- I would check for reversible causes of CPR, particularly a tension pneumothorax
- Disconnect from positive pressure ventilation if this has been started
- Consider ECPR in accordance with local protocols if initial resuscitation efforts are unsuccessful
The patient is successfully resuscitated and taken to ITU. The patient’s sister has arrived on the ward and your consultant has asked you to talk to them about what has happened. What should you consider before talking to the patient’s relative?
Breaking Bad News to a Relative in a Critical Care Setting:
Preparation:
* Clarify the medical facts with the consultant/senior.
* Confirm what information can be shared.
Environment:
- Find a private, quiet space with seating.
- Minimise interruptions (handover bleep if possible).
- Ask if they want someone else present for support.
Initiating the Conversation:
- Begin by exploring what they already know.
- Use clear, simple language with minimal medical jargon.
Delivering Difficult News:
- Provide information chronologically.
- Give warning shots before distressing details.
- Allow pauses for questions and emotional reactions.
Concluding the Discussion:
- Clarify if further information is needed.
- Offer a chance to visit ITU after confirming with staff.
- Provide contact information for ongoing updates.
Documentation:
- Record key points of the conversation in the medical notes.
Key Principles: Compassion, clarity, honesty, and emotional support.
This question is all about communication skills. The interviewers want you to demonstrate that you understand this is a difficult situation and you would think before talking to the relative. This means thinking about your environment and checking with your team about what you are going to say.
The patient is discussed at the medical handover at the end of your shift. Please sum up the course of events and hand over to the medical team.
You must practice this yourself, the back of the flaschard just an exmaple
S: This is a 19-year-old who is currently receiving post-resus care on ITU, having had a cardiac arrest due to a life-threatening asthma attack.
B: He has a background of childhood asthma but has never previously been admitted to hospital due to an exacerbation.
A: On initial assessment, he was found to be having a life-threatening asthma attack due to hypoxia, and a PEF of 30% of predicted. He was initially treated with steroids, β₂ agonists, ipratropium nebs and IV magnesium sulfate. However, he subsequently arrested on the ward, and was resuscitated following a 2222 call. He is currently intubated on ITU. I have spoken with the patient’s relatives about what has happened, after discussion with the senior medical team.
R: he will need to be re-assessed on ITU, and further investigations such as a chest x-ray arranged. I would suggest that a follow up consultation is held with the family following the post-take ward round as they are likely to have further questions and will need to be updated with the patient’s progress. Once stabilised, he will need to be reviewed to establish the cause of the initial exacerbation, and I would suggest that they are referred to the respiratory team to be reviewed during this admission and assess the management of their asthma.
