CICM SAQ 2010.2 Q2
Questions
A 36 year old female is brought into your Emergency Department with acute shortness of breath. She is unable to provide any history due to her tachypnoea. She is sitting upright in bed grasping the bed sides. She has a respiratory rate of 30 breaths per minute, has a GCS of 15, is afebrile and has a BP of 90/60mmHg. She is using accessory muscles. On auscultation, she has widespread expiratory wheeze spread throughout both lung fields.
- a) In addition to acute severe asthma, what other differential diagnoses of her clinical presentation should be considered?
- b) Assuming this patient has acute severe asthma, list your initial management steps at this stage.
- c) Despite optimal medical management, the patient tires. Briefly outline the role of BiPAP in acute severe asthma.
- d) BiPAP fails and the patient is successfully intubated. Following intubation, airway pressures rise and the chest becomes more silent. List other interventions may you consider.
Answers
Answer and interpretation
a) In addition to acute severe asthma, what other differential diagnoses of her clinical presentation should be considered?
- anaphylaxis ( large % don’t have rash etc – just bronchospasm)
- Acute exacerbation COPD
- central foreign body
- acute pulmonary oedema
- Pneumothorax
- Hysterical hyperventilation
- acute pulmonary embolus
b) Assuming this patient has acute severe asthma, list your initial management steps at this stage.
- Resuscitation/ investigation and definitive management
- Initial salbutamol nebulisation – continuously. Consider IV infusion
- IV steroids – ? type and dose
- Replace K/Mg
- Nebulised adrenalin if anaphylaxis still under consideration
- IV access, bloods including mast cell tryptase cultures/ +/- procalcitonin
- Portable CXR to exclude pnemothorax / localised consolidation and assess hyperinflation.
c) Despite optimal medical management, the patient tires. Briefly outline the role of BiPAP in acute severe asthma.
Intrinisic PEEP increases the negative intrathoracic pressure the patient must generate to trigger a breath and hence increases WOB. Application of extrinsic PEEP minimises this difference and reduces WOB. IPAP reduces the WOB associated with resistance.
d) BiPAP fails and the patient is successfully intubated. Following intubation, airway pressures rise and the chest becomes more silent. List other interventions may you consider.
- Another CXR to check no PTX post PPV
- Increasing salbutamol
- Deepen sedation
- Adding adrenalin/ aminophylline/ ketamine/ Mg ( no evidence) – doses required
- by candidate
- Volatile anaesthesia
- Paralysis- Train of four essential .
- ? bronchoscopy
- Measurement of iPEEP
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CICM
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
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