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.
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
- 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
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.